Abstract
BACKGROUND: Deaths of despair are a key contributor to stagnating life expectancy in the USA, especially among those without a university-level education, but these findings have not been compared internationally. METHODS: Mortality and person-year population exposure data were collected in 14 Organisation for Economic Co-operation and Development member countries and stratified by age, sex, educational attainment and cause of death. The sample included 1.4 billion person-year observations from persons aged ≥25 years between 2013 and 2019. Country-specific and sex-specific contributions of deaths of despair to: (a) the life expectancy gap at age 25 and (b) rate differences in age-standardised mortality rates between high and low educational attainment groups were calculated. RESULTS: Eliminating deaths of despair could reduce the life expectancy gap in the USA by 1.1 years for men and 0.6 years for women was second only to Korea, where it would reduce the gap by 3.4 years for men and 2.2 years for women. In Italy, Spain and Türkiye, eliminating deaths of despair would improve life expectancy gains by less than 0.1 years for women and 0.3 years for men, closing the educational gap by <1%. Findings were robust to controls for differences in population structures. CONCLUSIONS: Deaths of despair are a major determinant of educational inequalities in longevity in Korea and the USA, while having limited impact in Southern European countries, indicating substantial international variation and scope for improvement in high burden high-income countries.