BACKGROUND: In many countries smoking rates have declined and obesity rates have increased, and social inequalities in each have varied over time. At the same time, mortality has declined in most high-income countries, but gaps by educational qualification persist-at least partially due to differential smoking and obesity distributions. This study uses a compass typology to simultaneously examine the magnitude and trends in educational inequalities across multiple countries in: a) smoking and obesity; b) smoking-related mortality and c) cause-specific mortality. METHODS: Smoking prevalence, obesity prevalence and cause-specific mortality rates (35-79 year olds by sex) in nine European countries and New Zealand were sourced from between 1980 and 2010. We calculated relative and absolute inequalities in prevalence and mortality (relative and slope indices of inequality, respectively RII, SII) by highest educational qualification. Countries were then plotted on a compass typology which simultaneously examines trends in the population average rates or odds on the x-axis, RII on the Y-axis, and contour lines depicting SII. FINDINGS: Smoking and obesity. Smoking prevalence in men decreased over time but relative inequalities increased. For women there were fewer declines in smoking prevalence and relative inequalities tended to increase. Obesity prevalence in men and women increased over time with a mixed picture of increasing absolute and sometimes relative inequalities. Absolute inequalities in obesity increased for men and women in Czech Republic, France, New Zealand, Norway, for women in Austria and Lithuania, and for men in Finland. Cause-specific mortality. Average rates of smoking-related mortality were generally stable or increasing for women, accompanied by increasing relative inequalities. For men, average rates were stable or decreasing, but relative inequalities increased over time. Cardiovascular disease, cancer, and external injury rates generally decreased over time, and relative inequalities increased. In Eastern European countries mortality started declining later compared to other countries, however it remained at higher levels; and absolute inequalities in mortality increased whereas they were more stable elsewhere. CONCLUSIONS: Tobacco control remains vital for addressing social inequalities in health by education, and focus on the least educated is required to address increasing relative inequalities. Increasing obesity in all countries and increasing absolute obesity inequalities in several countries is concerning for future potential health impacts. Obesity prevention may be increasingly important for addressing health inequalities in some settings. The compass typology was useful to compare trends in inequalities because it simultaneously tracks changes in rates/odds, and absolute and relative inequality measures.

Department of Epidemiology and Biostatistics the National Institute for Health Development Estonia Sweden

Department of Public Health Erasmus MC Rotterdam Netherlands

Department of Public Health University of Otago Dunedin New Zealand

Department of Public Health University of Otago Wellington Wellington New Zealand

Faculty of Public Health Lithuanian University of Health Sciences Kaunas Lithuania

Faculty of Science Charles University Prague Czech Republic

Melbourne School of Population and Global Health University of Melbourne Melbourne Victoria Australia

Population Research Unit Faculty of Social Sciences University of Helsinki Helsinki Finland

Stockholm Centre for Health and Social Change Södertörn University Huddinge Sweden

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Giskes K, Kunst AE, Benach J, et al. Trends in smoking behaviour between 1985 and 2000 in nine European countries by education. J Epidemiol Community Health. 2005;59(5):395–401. Epub 2005/04/16. 10.1136/jech.2004.025684 . PubMed DOI PMC

Huisman M, Kunst AE, Mackenbach JP. Educational inequalities in smoking among men and women aged 16 years and older in 11 European countries. Tob Control. 2005;14(2):106–13. Epub 2005/03/26. 10.1136/tc.2004.008573 . PubMed DOI PMC

Huisman M, Kunst AE, Mackenbach JP. Inequalities in the prevalence of smoking in the European Union: comparing education and income. Prev Med. 2005;40(6):756–64. Epub 2005/04/27. 10.1016/j.ypmed.2004.09.022 . PubMed DOI

Jha P, Peto R, Zatonski W, et al. Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America. The Lancet. 2006;368(9533):367–70. 10.1016/s0140-6736(06)68975-7 PubMed DOI

Gregoraci G, Lenthe FJv, Artnik B, et al. Contribution of smoking to socioeconomic inequalities in mortality: a study of 14 European countries, 1990–2004. Tobacco Control. 2017;26:206–68. 10.1136/tobaccocontrol2015-052766 PubMed DOI

Martikainen P, Ho JY, Preston S, et al. The changing contribution of smoking to educational differences in life expectancy: indirect estimates for Finnish men and women from 1971 to 2010. J Epidemiol Community Health. 2013;67(3):219–24. 10.1136/jech-2012-201266 . PubMed DOI PMC

Blakely T, Wilson N. The contribution of smoking to inequalities in mortality by education varies over time and by sex: two national cohort studies, 1981–84 and 1996–99. Int J Epidemiol. 2005;34(5):1054–62. 10.1093/ije/dyi172 . PubMed DOI

Teng A, Atkinson J, Disney G, et al. Changing smoking-mortality association over time and across social groups: National census-mortality cohort studies from 1981 to 2011. Sci Rep. 2017;7(1):11465 10.1038/s41598-017-11785-x . PubMed DOI PMC

Aune D, Sen A, Prasad M, et al. BMI and all cause mortality: systematic review and non-linear dose-response meta-analysis of 230 cohort studies with 3.74 million deaths among 30.3 million participants. BMJ. 2016;353:i2156 10.1136/bmj.i2156 . PubMed DOI PMC

Bono F, Matranga D. Socioeconomic inequality in non-communicable diseases in Europe between 2004 and 2015: evidence from the SHARE survey. Eur J Public Health. 2018. Epub 2018/09/01. 10.1093/eurpub/cky165 . PubMed DOI PMC

Hoffmann R, Eikemo TA, Kulhanova I, et al. Obesity and the potential reduction of social inequalities in mortality: evidence from 21 European populations. Eur J Public Health. 2015;25(5):849–56. 10.1093/eurpub/ckv090 . PubMed DOI

Vallejo-Torres L, Morris S. The contribution of smoking and obesity to income-related inequalities in health in England. Soc Sci Med. 2010;71(6):1189–98. Epub 2010/07/16. 10.1016/j.socscimed.2010.06.008 . PubMed DOI

Mackenbach JP, Kulhanova I, Menvielle G, et al. Trends in inequalities in premature mortality: a study of 3.2 million deaths in 13 European countries. J Epidemiol Community Health. 2014;69(3):207–17. 10.1136/jech-2014-204319 . PubMed DOI

Blakely T, Disney G, Atkinson J, et al. A typology for charting socioeconomic mortality gradients:" Go south-west". Epidemiology. 2017;28(4):594–603. 10.1097/EDE.0000000000000671 PubMed DOI

Mackenbach JP, Valverde JR, Bopp M, et al. Determinants of inequalities in life expectancy: an international comparative study of eight risk factors. The Lancet Public Health. 2019;4(10):e529–e37. 10.1016/S2468-2667(19)30147-1 PubMed DOI

Mackenbach JP, Kulhanova I, Artnik B, et al. Changes in mortality inequalities over two decades: register based study of European countries. BMJ. 2016;353:i1732 10.1136/bmj.i1732 . PubMed DOI PMC

Hu Y, van Lenthe FJ, Platt S, et al. The Impact of Tobacco Control Policies on Smoking Among Socioeconomic Groups in Nine European Countries, 1990–2007. Nicotine Tob Res. 2017;19(12):1441–9. Epub 2016/09/11. 10.1093/ntr/ntw210 . PubMed DOI

Hoffmann K, De Gelder R, Hu Y, et al. Trends in educational inequalities in obesity in 15 European countries between 1990 and 2010. Int J Behav Nutr Phys Act. 2017;14(1):63 Epub 2017/05/10. 10.1186/s12966-017-0517-8 . PubMed DOI PMC

Mackenbach J, Kulhánová I, Artnik B, et al. Changes over two decades in inequalities in mortality: a registered-based study of 11 European countries. BMJ. 2016;353:i1732 10.1136/bmj.i1732. PubMed DOI PMC

Mackenbach JP, Kulhanova I, Bopp M, et al. Inequalities in Alcohol-Related Mortality in 17 European Countries: A Retrospective Analysis of Mortality Registers. PLoS Med. 2015;12(12):e1001909 10.1371/journal.pmed.1001909 . PubMed DOI PMC

Blakely T, Tobias M, Atkinson J, et al. Tracking Disparity: Trends in ethnic and socioeconomic inequalities in mortality, 1981–2004. Wellington Ministry of Health, 2007. August 2007. Report No.

Fawcett J, Atkinson J, Blakely T. Record linkage of census and mortality 2001–04 records Wellington Health Inequalities Research Programme, University of Otago, Wellington, 2008.

Tobias M, Blakely T, Matheson D, et al. Changing trends in indigenous inequalities in mortality: lessons from New Zealand. Int J Epidemiol. 2009;38(6):1711–22. 10.1093/ije/dyp156 PubMed DOI

Blakely T, Tobias M, Atkinson J. Inequalities in mortality during and after restructuring of the New Zealand economy: repeated cohort studies. BMJ. 2008;336:371–5. 10.1136/bmj.39455.596181.25 PubMed DOI PMC

Blakely T, Fawcett J, Hunt D, et al. What is the contribution of smoking and socioeconomic position to ethnic inequalities in mortality in New Zealand? The Lancet. 2006;368(9529):44–52. PubMed

Sloane K, Atkinson J, Bastiampillai N, et al. Record linkage of 2006 census records and 2006–2011 mortality and cancer registration records: unlock ratios and linkage weights. Wellington: 2015.

Lopez AD, Collishaw NE, Piha T. A descriptive model of the cigarette epidemic in developed countries. Tob Control. 1994;3:242–7.

Lynch J, Smith GD. A life course approach to chronic disease epidemiology. Annu Rev Public Health. 2005;26:1–35. 10.1146/annurev.publhealth.26.021304.144505 . PubMed DOI

Tekkel M, Veideman T, Rahu M. Changes over fourteen years in adult obesity in Estonia: socioeconomic status and use of outpatient services. Cent Eur J Public Health. 2010;18(4):186–91. 10.21101/cejph.b0413 PubMed DOI

Popkin BM. The nutrition transition and its health implications in lower-income countries. Public health nutrition. 1998;1(1):5–21. 10.1079/phn19980004 PubMed DOI

Capewell S, Buchan I. Why have sustained increases in obesity and type 2 diabetes not offset declines in cardiovascular mortality over recent decades in Western countries? Nutr Metab Cardiovasc Dis. 2012;22(4):307–11. Epub 2012/03/13. 10.1016/j.numecd.2012.01.005 . PubMed DOI

Cecchini M, Sassi F, Lauer JA, et al. Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness. The Lancet. 2010;376(9754):1775–84. 10.1016/s0140-6736(10)61514-0 PubMed DOI

Okunade AA, Rubin RM, Okunade AK. Delayed Effects of Obese and Overweight Population Conditions on All-Cause Adult Mortality Rate in the USA. Front Public Health. 2016;4:212 Epub 2016/10/14. 10.3389/fpubh.2016.00212 . PubMed DOI PMC

Capewell S, O'Flaherty M. Rapid mortality falls after risk-factor changes in populations. The Lancet. 2011;378(9793):752–3. 10.1016/s0140-6736(10)62302-1 PubMed DOI

Shkolnikov VM, Jasilionis D, Andreev EM, et al. Linked versus unlinked estimates of mortality and length of life by education and marital status: evidence from the first record linkage study in Lithuania. Soc Sci Med. 2007;64(7):1392–406. Epub 2007/01/02. 10.1016/j.socscimed.2006.11.014 . PubMed DOI

Renard F, Devleesschauwer B, Speybroeck N, et al. Monitoring health inequalities when the socio-economic composition changes: are the slope and relative indices of inequality appropriate? Results of a simulation study. BMC Public Health. 2019;19(1):662 Epub 2019/05/31. 10.1186/s12889-019-6980-1 PubMed DOI PMC