Olof Östergren

Olof Östergren


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Works at Department of Public Health Sciences
Telephone 08-16 36 40
Visiting address Albanovägen 12 Plan 5
Room 558
Postal address Institutionen för folkhälsovetenskap 114 19 Stockholm


A selection from Stockholm University publication database
  • 2020. Olof Östergren, Martikainen Pekka. Scandinavian Journal of Public Health 48 (3), 346-349

    Aims: In recent decades, smoking-related mortality has declined among men and increased among women in Sweden. We estimate the contribution of smoking-related deaths to the narrowing of the gender gap in life expectancy in Sweden between 1997 and 2016.

    Methods: We extracted population data on deaths and population under risk on the entire Swedish population aged 25 years and over for the period 1997–2016. Smoking-related mortality was assessed using an indirect method based on lung cancer mortality. We then estimated the contribution of smoking to the gender gap in life expectancy by comparing the observed life expectancies to life expectancies excluding smoking-related deaths.

    Results: The gender gap in life expectancy was 5.0 years in 1997 and 3.4 years in 2016. The gender gap narrowed by 1.6 years, of which 0.6 years were attributable to smoking-related deaths.

    Conclusions: The combination of decreasing smoking-related mortality among men and increasing smoking-related mortality among women in Sweden accounted for almost 40% of the narrowing of the gender gap in life expectancy during the period 1997–2016.

  • 2019. Kjetil A. van der Wel (et al.). Scandinavian Journal of Public Health 47 (6), 618-630

    Aims: Future research on health inequality relies on data that cover life-course exposure, different birth cohorts and variation in policy contexts. Nordic register data have long been celebrated as a 'gold mine' for research, and fulfil many of these criteria. However, access to and use of such data are hampered by a number of hurdles and bottlenecks. We present and discuss the experiences of an ongoing Nordic consortium from the process of acquiring register data on socio-economic conditions and health in Denmark, Finland, Norway and Sweden. Methods: We compare experiences of data-acquisition processes from a researcher's perspective in the four countries and discuss the comparability of register data and the modes of collaboration available to researchers, given the prevailing ethical and legal restrictions. Results: The application processes we experienced were time-consuming, and decision structures were often fragmented. We found substantial variation between the countries in terms of processing times, costs and the administrative burden of the researcher. Concerned agencies differed in policy and practice which influenced both how and when data were delivered. These discrepancies present a challenge to comparative research. Conclusions: We conclude that there are few signs of harmonisation, as called for by previous policy documents and research papers. Ethical vetting needs to be centralised both within and between countries in order to improve data access. Institutional factors that seem to facilitate access to register data at the national level include single storage environments for health and social data, simplified ethical vetting and user guidance.

  • 2019. Olof Östergren (et al.). Journal of Epidemiology and Community Health 73 (4), 334-339

    Background Despite being comparatively egalitarian welfare states, the Nordic countries have not been successful in reducing health inequalities. Previous studies have suggested that smoking and alcohol contribute to this pattern. Few studies have focused on variations in alcohol-related and smoking-related mortality within the Nordic countries. We assess the contribution of smoking and alcohol to differences in life expectancy between countries and between income quintiles within countries.

    Methods We collected data from registers in Denmark, Finland, Norway and Sweden comprising men and women aged 25–79 years during 1995–2007. Estimations of alcohol-related mortality were based on underlying and contributory causes of death on individual death certificates, and smoking-related mortality was based on an indirect method that used lung cancer mortality as an indicator for the population-level impact of smoking on mortality.

    Results About 40%–70% of the between-country differences in life expectancy in the Nordic countries can be attributed to smoking and alcohol. Alcohol-related and smoking-related mortality also made substantial contributions to income differences in life expectancy within countries. The magnitude of the contributions were about 30% in Norway, Sweden and among Finnish women to around 50% among Finnish men and in Denmark.

    Conclusions Smoking and alcohol consumption make substantial contributions to both between-country differences in mortality among the Nordic countries and within-country differences in mortality by income. The size of these contributions vary by country and sex.

  • 2019. Jon Ivar Elstad (et al.). Journal of International and Comparative Social Policy 35 (2), 157-176

    Income security when health impairment or other social risks occur is a major objective of welfare states. This comparative study uses register data from four Nordic welfare states for examining equivalized disposable income during the last 12 years alive among men and women who died when aged 55–69 years old. The analysed outcome indicates the aggregate result of a varied set of income maintenance mechanisms. Median income increased in the Finnish, Norwegian and Swedish samples, but decreased somewhat in Denmark, probably due to relatively frequent transitions to retirement and larger income drops after retirement than in the other Nordic countries. Analyses of comparison samples weighted by propensity scores indicated a better income development among those who lived beyond the observation period than among those who died. The higher educated had a more favourable income development during the years prior to death than those with low education.

  • 2018. Olof Östergren.

    Education develops skills that help individuals use available material resources more efficiently. When material resources are scarce, each decision becomes comparatively more important. Education may also protect from health-related income decline, since the highly educated tend to work in occupations with lower physical demands. Educational inequalities in health may, therefore, be more pronounced at lower levels of income. The aim of this study is to assess whether the shape of the income gradient in premature mortality depends on the level of education.

    Total population data on education, income and mortality was obtained by linking several Swedish registers. Income was defined as five-year average disposable household income for ages 35–64 and mortality follow-up covered the period 2006–2009. The final population comprised 2.3 million individuals, 6.2 million person-years and 14,362 deaths. Income was modeled using splines in order to allow variation in the functional form of the association across educational categories. Poisson regression with robust standard errors was used.

    The curvilinear shape of the association between income and mortality was more pronounced among those with a low education. Both absolute and relative educational inequalities in premature mortality tended to be larger at low levels of income. The greatest income differences in mortality were observed for those with a low education and the smallest for the highly educated.

    Education and income interact as predictors of mortality. Education is a more important factor for health when access to material resources is limited.

  • 2018. Olof Östergren, Pekka Martikainen, Olle Lundberg. International Journal of Public Health 63 (1), 41-48


    To assess the level and changes in contribution of smoking and alcohol-related mortality to educational differences in life expectancy in Sweden.


    We used register data on the Swedish population at ages 30–74 during 1991–2008. Cause of death was used to identify alcohol-related deaths, while smoking-related mortality was estimated using lung cancer mortality to indirectly assess the impact of smoking on all-cause mortality.


    Alcohol consumption and smoking contributed to educational differences in life expectancy. Alcohol-related mortality was higher among men and contributed substantially to inequalities among men and made a small (but increasing) contribution to inequalities among women. Smoking-related mortality decreased among men but increased among women, primarily among the low educated. At the end of the follow-up, smoking-related mortality were at similar levels among men and women. The widening gap in life expectancy among women could largely be attributed to smoking.


    Smoking and alcohol consumption contribute to educational differences in life expectancy among men and women. The majority of the widening in the educational gap in mortality among women can be attributed to alcohol and smoking-related mortality.

  • 2017. Olof Östergren (et al.). PLoS ONE 12 (8)


    The aim of this paper is to empirically evaluate whether widening educational inequalities in mortality are related to the substantive shifts that have occurred in the educational distribution.

    Materials and methods

    Data on education and mortality from 18 European populations across several decades were collected and harmonized as part of the Demetriq project. Using a fixed-effects approach to account for time trends and national variation in mortality, we formally test whether the magnitude of relative inequalities in mortality by education is associated with the gender and age-group specific proportion of high and low educated respectively.


    The results suggest that in populations with larger proportions of high educated and smaller proportions of low educated, the excess mortality among intermediate and low educated is larger, all other things being equal.


    We conclude that the widening educational inequalities in mortality being observed in recent decades may in part be attributed to educational expansion.

  • 2017. Kimmo Herttua (et al.). Journal of Epidemiology and Community Health 71 (12), 1168-1176

    Background: Prices of alcohol and income tend to influence how much people buy and consume alcohol. Price and income may be combined into one measure, affordability of alcohol. Research on the association between affordability of alcohol and alcohol-related harm is scarce. Furthermore, no research exists on how this association varies across different subpopulations. We estimated the effects of affordability of alcohol on alcohol-related mortality according to gender and education in Finland and Sweden.

    Methods: Vector-autoregressive time series modelling was applied to the quarter-annual aggregations of alcohol-related deaths and affordability of alcohol in Finland in 1988–2007 and in Sweden in 1991–2008. Alcohol-related mortality was defined using information on both underlying and contributory causes of death. We calculated affordability of alcohol index using information on personal taxable income and prices of various types of alcohol.

    Results: Among Finnish men with secondary education,an increase of 1% in the affordability of total alcohol was associated with an increase of 0.028% (95% CI 0.004 to 0.053) in alcohol-related mortality. Similar associations were also found for affordability for various types of alcohol and for beer only in the lowest education group. We found few other significant positive associations for other subpopulations in Finland or Sweden. However, reverse associations were found among secondary-educated Swedish women.

    Conclusions: Overall, the associations between affordability of alcohol and alcohol-related mortality were relatively weak. Increased affordability of total alcoholic beverages was associated with higher rates of alcohol-related mortality only among Finnish men with secondary education.

  • 2017. Zakir Hossin, O Östergren, Stefan Fors. The journals of gerontology. Series B, Psychological sciences and social sciences
  • 2017. Olof Östergren, Olle Lundberg, Richard Layte.

    There is a positive association between education and longevity. Individuals with a university degree tend to live longer than high school graduates who, in turn, live longer than those with compulsory education. These differences are neither larger nor smaller in Sweden than in other European countries, despite its ambitious welfare-state policies. Furthermore, educational differences in longevity are growing, especially among women.

    In this thesis I look at the structural, individual and behavioral processes which generate and maintain the educational gradient in mortality. This is done by compiling theoretical insights and empirical research from a range of scientific disciplines. In doing so, this thesis aims to contribute to a more comprehensive understanding of the educational gradient in mortality.

    Several factors contribute to the association between education and health. Social and biological processes initiated in early life influence both educational achievement and adult health. Education helps individuals become more effective as agents by fostering generic skills such as information-gathering and decision-making. This aspect of education, learned effectiveness, promotes control and health regardless of available resources and prevailing conditions. Education thus has a direct influence on health. Education also indirectly influences health by giving access to better occupational positions and higher incomes, as well as by promoting social capital and healthy habits.

    The empirical section of the thesis consists of four separate quantitative studies using register data. Three of the studies use Swedish national register data while one uses register data from 18 European populations. The results indicate that widening income inequalities in mortality have contributed to a widening of educational inequalities in mortality, since education is a determinant of income. Both alcohol and smoking contribute to educational inequalities in longevity, but smoking has played an especially pronounced role in the widening of inequalities among women. Smoking represents a significant part of the explanation as to why women with low education have experienced smaller gains in life expectancy than the rest of the population. The results also indicate that the general trend towards more well-educated populations has contributed to the widening educational inequalities in mortality in Europe and that education is a stronger predictor of mortality among low income-earners than among the rest of the population.

  • 2016. J. P. Mackenbach (et al.). BMJ Open 353 (1732)

    Objective To determine whether government efforts in reducing inequalities in health in European countries have actually made a difference to mortality inequalities by socioeconomic group.

    Design Register based study.

    Data source Mortality data by level of education and occupational class in the period 1990-2010, usually collected in a census linked longitudinal study design. We compared changes in mortality between the lowest and highest socioeconomic groups, and calculated their effect on absolute and relative inequalities in mortality (measured as rate differences and rate ratios, respectively).

    Setting All European countries for which data on socioeconomic inequalities in mortality were available for the approximate period between years 1990 and 2010. These included Finland, Norway, Sweden, Scotland, England and Wales (data applied to both together), France, Switzerland, Spain (Barcelona), Italy (Turin), Slovenia, and Lithuania.

    Results Substantial mortality declines occurred in lower socioeconomic groups in most European countries covered by this study. Relative inequalities in mortality widened almost universally, because percentage declines were usually smaller in lower socioeconomic groups. However, as absolute declines were often smaller in higher socioeconomic groups, absolute inequalities narrowed by up to 35%, particularly among men. Narrowing was partly driven by ischaemic heart disease, smoking related causes, and causes amenable to medical intervention. Progress in reducing absolute inequalities was greatest in Spain (Barcelona), Scotland, England and Wales, and Italy (Turin), and absent in Finland and Norway. More detailed studies preferably using individual level data are necessary to identify the causes of these variations.

    Conclusions Over the past two decades, trends in inequalities in mortality have been more favourable in most European countries than is commonly assumed. Absolute inequalities have decreased in several countries, probably more as a side effect of population wide behavioural changes and improvements in prevention and treatment, than as an effect of policies explicitly aimed at reducing health inequalities.

  • Article Growing gaps
    2015. Olof Östergren. Scandinavian Journal of Public Health 43 (6), 563-570

    Aims: Although absolute levels of mortality have decreased among Swedish men and women in recent decades, educational inequalities in mortality have increased, especially among women. The aim of this study is to disentangle the role of income and family type in educational inequalities in mortality in Sweden during 1990-2009, focusing on gender differences. Methods: Data on individuals born in Sweden between the ages of 30 and 74 years were collected from total population registries, covering a total of 529,275 deaths and 729 million person-months. Temporary life expectancies (age 30-74 years) by education were calculated using life tables, and rate ratios were estimated with Poisson regression with robust standard errors. Results: Temporary life expectancy improved among all groups except low educated women. Relative educational inequalities in mortality (RRs) increased from 1.79 to 1.98 among men and from 1.78 to 2.10 among women. Variation in family type explained some of the inequalities among men, but not among women, and did not contribute to the trend. Variation in income explained a larger part of the educational inequalities among men compared to women and also explained the increase in educational inequalities in mortality among men and women. Conclusions: Increasing educational inequalities in mortality in Sweden may be attributed to the increase in income inequalities in mortality.

  • 2015. J. P. Mackenbach (et al.). Journal of Epidemiology and Community Health 69 (3), 207-217

    Background Over the last decades of the 20th century, a widening of the gap in death rates between upper and lower socioeconomic groups has been reported for many European countries. For most countries, it is unknown whether this widening has continued into the first decade of the 21st century. Methods We collected and harmonised data on mortality by educational level among men and women aged 30-74 years in all countries with available data: Finland, Sweden, Norway, Denmark, England and Wales, Belgium, France, Switzerland, Spain, Italy, Hungary, Lithuania and Estonia. Results Relative inequalities in premature mortality increased in most populations in the North, West and East of Europe, but not in the South. This was mostly due to smaller proportional reductions in mortality among the lower than the higher educated, but in the case of Lithuania and Estonia, mortality rose among the lower and declined among the higher educated. Mortality among the lower educated rose in many countries for conditions linked to smoking (lung cancer, women only) and excessive alcohol consumption (liver cirrhosis and external causes). In absolute terms, however, reductions in premature mortality were larger among the lower educated in many countries, mainly due to larger absolute reductions in mortality from cardiovascular disease and cancer (men only). Despite rising levels of education, population-attributable fractions of lower education for mortality rose in many countries. Conclusions Relative inequalities in premature mortality have continued to rise in most European countries, and since the 1990s, the contrast between the South (with smaller inequalities) and the East (with larger inequalities) has become stronger. While the population impact of these inequalities has further increased, there are also some encouraging signs of larger absolute reductions in mortality among the lower educated in many countries. Reducing inequalities in mortality critically depends upon speeding up mortality declines among the lower educated, and countering mortality increases from conditions linked to smoking and excessive alcohol consumption such as lung cancer, liver cirrhosis and external causes.

  • 2015. JP Mackenbach (et al.). Social Science and Medicine 127, 51-62

    Link and Phelan have proposed to explain the persistence of health inequalities from the fact that socioeconomic status is a “fundamental cause” which embodies an array of resources that can be used to avoid disease risks no matter what mechanisms are relevant at any given time. To test this theory we compared the magnitude of inequalities in mortality between more and less preventable causes of death in 19 European populations, and assessed whether inequalities in mortality from preventable causes are larger in countries with larger resource inequalities.

    We collected and harmonized mortality data by educational level on 19 national and regional populations from 16 European countries in the first decade of the 21st century. We calculated age-adjusted Relative Risks of mortality among men and women aged 30–79 for 24 causes of death, which were classified into four groups: amenable to behavior change, amenable to medical intervention, amenable to injury prevention, and non-preventable.

    Although an overwhelming majority of Relative Risks indicate higher mortality risks among the lower educated, the strength of the education–mortality relation is highly variable between causes of death and populations. Inequalities in mortality are generally larger for causes amenable to behavior change, medical intervention and injury prevention than for non-preventable causes. The contrast between preventable and non-preventable causes is large for causes amenable to behavior change, but absent for causes amenable to injury prevention among women. The contrast between preventable and non-preventable causes is larger in Central & Eastern Europe, where resource inequalities are substantial, than in the Nordic countries and continental Europe, where resource inequalities are relatively small, but they are absent or small in Southern Europe, where resource inequalities are also large.

    In conclusion, our results provide some further support for the theory of “fundamental causes”. However, the absence of larger inequalities for preventable causes in Southern Europe and for injury mortality among women indicate that further empirical and theoretical analysis is necessary to understand when and why the additional resources that a higher socioeconomic status provides, do and do not protect against prevailing health risks.

  • 2014. Margarete C Kulik (et al.). Nicotine & tobacco research 16 (5), 507-518

    INTRODUCTION: Smoking is an important determinant of socioeconomic inequalities in mortality in many countries. As the smoking epidemic progresses, updates on the development of mortality inequalities attributable to smoking are needed. We provide estimates of relative and absolute educational inequalities in mortality from lung cancer, aerodigestive cancers, and chronic obstructive pulmonary disease (COPD)/asthma in Europe for the early 2000s and assess the contribution of these smoking-related diseases to inequalities in all-cause mortality.

    METHODS: We use data from 18 European populations covering the time period 1998-2007. We present age-adjusted mortality rates, relative indices of inequality, and slope indices of inequality. We also calculate the contribution of inequalities in smoking-related mortality to inequalities in overall mortality.

    RESULTS: Among men, relative inequalities in mortality from the 3 smoking-related causes of death combined are largest in the Czech Republic and Hungary and smallest in Spain, Sweden, and Denmark. Among women, these inequalities are largest in Scotland and Norway and smallest in Italy and Spain. They are often larger among men and tend to be larger for COPD/asthma than for lung and aerodigestive cancers. Relative inequalities in mortality from these conditions are often larger in younger age groups, particularly among women, suggesting a possible further widening of inequalities in mortality in the coming decades. The combined contribution of these diseases to inequality in all-cause mortality varies between 13% and 32% among men and between -5% and 30% among women.

    CONCLUSION: Our results underline the continuing need for tobacco control policies, which take into account socioeconomic position.

  • 2014. Netta E. Mäki (et al.). Journal of Epidemiology and Community Health 68 (7), 653-640

    Introduction This study assesses the effects of obesity, physical inactivity and smoking on life expectancy (LE) differences between educational groups in five European countries in the early 2000s. Methods We estimate the contribution of risk factors on LE differences between educational groups using the observed risk factor distributions and under a hypothetically more optimal risk factor distribution. Data on risk factor prevalence were obtained from the Survey of Health, Ageing and Retirement in Europe study, and data on mortality from census-linked data sets for the age between 50 and 79 according to sex and education. Results Substantial differences in LE of up to 2.8 years emerged between men with a low and a high level of education in Denmark, Austria and France, and smaller differences among men in Italy and Spain. The educational differences in LE were not as large among women. The largest potential for reducing educational differences was in Denmark (25% among men and 41% among women) and Italy (14% among men). Conclusions The magnitude of the effect of unhealthy behaviours on educational differences in LE varied between countries. LE among those with a low or medium level of education could increase in some European countries if the behavioural risk factor distributions were similar to those observed among the highly educated.

  • 2013. Netta Mäki (et al.). Social Science and Medicine 94, 1-8

    Healthy life expectancy is a composite measure of length and quality of life and an important indicator of health in aging populations. There are few cross-country comparisons of socioeconomic differences in healthy life expectancy. Most of the existing comparisons focus on Western Europe and the United States, often relying on older data. To address these deficiencies, we estimated educational differences in disability-free life expectancy for eight countries from all parts of Europe in the early 2000s. Long-standing severe disability was measured as a Global Activity Limitation Indicator (GALI) derived from the European Union Statistics on Income and Living Conditions (EU-SILC) survey. Census-linked mortality data were collected by a recent project comparing health inequalities between European countries (the EURO-GBD-SE project). We calculated sex-specific educational differences in disability-free life expectancy between the ages of 30 and 79 years using the Sullivan method. The lowest disability-free life expectancy was found among Lithuanian men and women (33.1 and 39.1 years, respectively) and the highest among Italian men and women (42.8 and 44.4 years, respectively). Life expectancy and disability-free life expectancy were directly related to the level of education, but the educational differences were much greater in the latter in all countries. The difference in the disability-free life expectancy between those with a primary or lower secondary education and those with a tertiary education was over 10 years for males in Lithuania and approximately 7 years for males in Austria, Finland and France, as well as for females in Lithuania. The difference was smallest in Italy (4 and 2 years among men and women, respectively). Highly educated Europeans can expect to live longer and spend more years in better health than those with lower education. The size of the educational difference in disability-free life expectancy varies significantly between countries. The smallest and largest differences appear to be in Southern Europe and in Eastern and Northern Europe, respectively.

  • 2013. M. C. Kulik (et al.). European Journal of Epidemiology 28 (12), 959-971

    Socioeconomic inequalities in health and mortality remain a widely recognized problem. Countries with smaller inequalities in smoking have smaller inequalities in mortality, and smoking plays an important part in the explanation of inequalities in some countries. We identify the potential for reducing inequalities in all-cause and smoking-related mortality in 19 European populations, by applying different scenarios of smoking exposure. Smoking prevalence information and mortality data come from 19 European populations. Prevalence rates are mostly taken from National Health Surveys conducted around the year 2000. Mortality rates are based on country-specific longitudinal or cross-sectional datasets. Relative risks come from the Cancer Prevention Study II. Besides all-cause mortality we analyze several smoking-related cancers and chronic obstructive pulmonary disease/asthma. We use a newly-developed tool to quantify the changes in population health potentially resulting from modifying the population distribution of exposure to smoking. This tool is based on the epidemiological measure of the population attributable fraction, and estimates the impact of scenario-based distributions of smoking on educational inequalities in mortality. The potential reduction of relative inequality in all-cause mortality between those with high and low education amounts up to 26 % for men and 32 % for women. More than half of the relative inequality may be reduced for some causes of death, often in countries of Northern Europe and in Britain. Patterns of potential reduction in inequality differ by country or region and sex, suggesting that the priority given to smoking as an entry-point for tackling health inequalities should differ between countries.

Show all publications by Olof Östergren at Stockholm University

Last updated: September 2, 2021

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