BACKGROUND: To assess trends in adult mortality among the US White population by education level, and to examine the major causes that account for the differential rates between less and more educated, with an emphasis on smoking-attributable diseases, opioids, and other causes contributing to what have been termed “deaths of despair.”
METHODS: Using national mortality and population data from 1989 to 2019, we quantified mortality among White individuals aged 15-79, by education level: 0-11 years (low), 12 years (middle), and 13+ years (high). We estimated smoking-attributable mortality by linking lung cancer mortality rates with relative risks for other smoking-related diseases. We analyzed deaths from opioids, cirrhosis, and other causes separately.
RESULTS: Between 1989 and 2019, absolute mortality rates widened sharply between low- and middle-education versus high-education groups. By 2019, the probability of death between ages 15-79 was 30% for high-education Whites, compared to 74% for low-education Whites. Smoking-attributable mortality rose substantially in low-education Whites but declined in middle- and high-education groups. Opioid mortality rose across all education levels, especially after 2010. Among 5.3 million excess premature deaths in the two lower education groups, 58% were due to smoking, while 9% were due to opioids, cirrhosis, and other external causes (accidents and violence) combined.
CONCLUSIONS: Although deaths from opioids and external causes rose throughout the decade ending in 2019, smoking remains the primary driver of stagnating survival rates among White US adults, causing nearly six times the percentage of deaths as opioids and other causes. All of these causes require public health attention, but the focus on reducing “deaths of despair” must retain a heavy emphasis on smoking-related deaths.