IARC 60th Anniversary - 19-21 May 2026
Session : Rapid Fire
Educational inequalities in tobacco-related cancer mortality in the European Union and the United Kingdom
TESHIMA A. 1, POSSENTI I. 2, LUGO A. 2, GALLUS S. 2, FILIPPIDIS5 F. 3, FELIU A. 3, ZADNIK V. 5, NUSSELDER W. 6, DALTON S. 7, MARTA M. 8, GIRVALAKI C. 9, RADU-LOGHIN C. 9, VARDAVAS C. 10, MARTÍNEZ C. 4,11,12,13, ESTEVE F. 4,11,12,14, SHEIKH M. 1, VACCARELLA S. 15, SOERJOMATARAM I. 15, RUMGAY H. 15
1 Early Detection, Prevention, and Infections Branch, International Agency for Research on Cancer, Lyon, France; 2 Department of Medical Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy; 3 Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom; 4 CIBER en Enfermedades Respiratorias (CIBERES), Madrid, Spain; 5 Slovenian Cancer Registry, Institute of Oncology, Ljubljana, Slovenia; 6 Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands; 7 Cancer Survivorship, Danish Cancer Institute, Copenhagen, Denmark; 8 Cancer Epidemiology and Primary Prevention Department, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland; 9 European Network for Smoking and Tobacco Prevention (ENSP), Brussels, Belgium; 10 National and Kapodistrian University of Athens, Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, Athens, Greece; 11 Tobacco Control Unit, WHO Collaborating Centre for Tobacco Control, Catalan Institute of Oncology (ICO), L’Hospitalet de Llobregat, Spain; 12 Tobacco Control Research Group, Institut d’Investigació Mčdica de Bellvitge – IDIBELL, L'Hospitalet de Llobregat , Spain; 13 School of Nursing, Universitat de Barcelona, Barcelona, Spain; 14 Secretariat of Public Health, Department of Health, Government of Catalonia, Barcelona, Spain; 15 Cancer Surveillance Branch, International Agency for Research on Cancer, Lyon, France
Background
Educational inequalities in both tobacco smoking behaviour and cancer mortality persist across Europe, yet the extent to which inequalities in smoking contribute to cancer mortality remains underexplored. Conventional indicators such as smoking prevalence do not reflect the duration or intensity of smoking. Lifetime smoking exposure indicators such as pack-years may provide a more precise estimate of cancer risk. This is particularly important for assessing educational inequalities in cancer mortality, as lower-educated groups accumulate far greater lifetime smoking exposure.
Objectives
This study estimated the contribution of smoking based on pack-years and of educational inequalities in smoking to cancer mortality across 28 European countries in 2022.
Methods
Population attributable fractions (PAFs) for smoking were estimated using categorised pack-years from 0.1-7.4 to 95+ as an indicator of lifetime smoking exposure, obtained from the Special Eurobarometer surveys (2017-2020; n=56,201 aged ≥15), and relative risks for smoking-related cancers from published meta-analyses. These PAFs were applied to GLOBOCAN 2022 mortality data to estimate all cancer deaths by age and education level in each country and sex. Population preventable fractions were calculated using a counterfactual scenario in which all educational groups were assigned the lowest exposure distribution observed within each country.
Results
An estimated 332,000 cancer deaths or 22.5% (95% uncertainty interval, UI: 20.0%–25.0%) of all cancer deaths in Europe in 2022 were attributable to tobacco smoking. Men accounted for 70.4% of these deaths, and lung cancer alone represented more than 60% of tobacco-attributable cancer deaths (203,800; 189,200–216,900). PAFs for men were lowest in Northen Europe (23.0% [19.7%-26.0%]) and highest in Eastern Europe (32.6% [29.6%-35.4%]). PAFs for women were lowest in Southern Europe (11.7% [9.7%-13.7%]) and highest in Northern Europe (17.9% [15.5%-20.2%]). Our findings show overall mean pack-years were approximately 1.5 times higher among lower-educated than higher-educated groups in both sexes, and a similar pattern in tobacco-attributable cancer mortality was found for men. However, these gradients were less consistent for women, with some Southern and Eastern European countries showing lower PAFs in the lower-educated groups. If educational inequalities in smoking within countries were eliminated, an estimated 60,000 cancer deaths could have been prevented, corresponding to 17.5% of tobacco-attributable cancer deaths (16.2% among men and 20.7% among women).
Conclusions/ Implications for practice or policy
Tobacco smoking continues to be a major contributor to cancer mortality in Europe, accounting for nearly one in four of all cancer deaths. While educational inequalities in smoking do not fully explain the cancer burden attributable to tobacco, approximately one in six such deaths could be prevented by reducing educational differences in smoking. Educational inequalities in tobacco-attributable cancer mortality therefore warrant continued monitoring, as their contribution may increase over time. Achieving substantial reductions in this burden will require sustained population-wide declines in smoking combined with strategies and gains that ensure these benefits reach all socioeconomic groups.