Academic journal article Demographic Research

The Contribution of Smoking to Regional Mortality Differences in the Netherlands

Academic journal article Demographic Research

The Contribution of Smoking to Regional Mortality Differences in the Netherlands

Article excerpt



Smoking is an important preventable determinant of morbidity and mortality. Knowledge about its role in regional mortality differences can help us to identify relevant policy areas, and to explain national mortality differences.


We explored the extent to which the regional differences in all-cause mortality in the Netherlands could be due to smoking by examining its link with regional differences in smoking-attributable mortality.


All-cause mortality, lung cancer mortality, and population numbers were obtained from Statistics Netherlands for the period 2004-2008, by 40 NUTS-3 regions, age, and sex. Smoking-attributable mortality was estimated using an adapted indirect Peto-Lopez method. We mapped regional differences in age-standardised all-cause mortality, smoking-attributable mortality fractions, and smoking- and non-smoking-related mortality rates. We assessed spatial clustering, calculated correlations, and compared and decomposed regional variance.


Significant regional differences in all-cause mortality, exhibiting a random pattern, were found. Smoking-attributable mortality fractions, which ranged from 22% to 30% among males and 7% to 14% among females, correlated significantly with all-cause mortality, especially among males. Smoking-attributable mortality varied far more than all-cause mortality, while non-smoking-attributable mortality varied less than all-cause mortality. The variance in smoking-attributable mortality contributed 39% to the regional variance in all-cause mortality among males, and 30% among females.


Smoking-attributable mortality thus clearly contributed to the regional differences in all-cause mortality, especially among males. This finding can be linked to past regional differences in smoking behaviour and underlying regional differences in socio-economic variables.

1. Introduction

It is well known that smoking is an important and preventable determinant of morbidity and mortality. Smoking contributes strongly to cancer of the lung, COPD, and cancer of the upper respiratory and digestive system; and to a lesser extent to coronary heart disease, stroke, and cancer of the bladder, stomach, kidney, and pancreas (U.S. Department of Health and Human Services 2004). Several studies have found large gaps in the life expectancies of smokers and non-smokers, amounting to between six and 10 years (Doll et al. 2004, Mamun et al. 2004, van Baal et al. 2006). Within Europe, smoking is the leading risk factor for premature mortality, and it has the greatest impact on the disease burden of all of the preventable lifestyle factors (World Health Organization 2002).

The smoking epidemic has increased national mortality levels over a long period of time, firstly and more strongly for males than for females, with a time lag of about 30 years between the increase plus subsequent decline in smoking prevalence, and the increase plus subsequent decline in smoking-attributable mortality (Lopez, Collishaw, and Piha 1994). Countries differ, however, in the timing of the onset of the epidemic, and in the pace at which they go through it. In Northern and Western Europe, the prevalence of smoking has been declining for several decades, especially for males. Consequently, smoking-attributable mortality in these regions has been decreasing for males, whereas for females, the peak is approaching. In Eastern Europe, smoking- attributable mortality among males is either peaking or just beginning to decline, whereas for females, it is still on the increase (Shafey, Dolwick, and Guindon 2003).

Because of the important international differences in smoking and subsequent smoking-attributable mortality (e.g. Ezzati and Lopez 2004), many studies on the determinants of all-cause mortality differences between countries have looked into the role of smoking, and have found that smoking has had a significant impact (e. …

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