Modifiable causes of premature death in middle-age in Western Europe: Results from the EPIC cohort study

David C. Muller, Neil Murphy, Mattias Johansson, Pietro Ferrari, Konstantinos K. Tsilidis, Marie Christine Boutron-Ruault, Francoise Clavel, Laureen Dartois, Kuanrong Li, Rudolf Kaaks, Cornelia Weikert, Manuela Bergmann, Heiner Boeing, Anne Tjønneland, Kim Overvad, M. Luisa Redondo, Antonio Agudo, Elena Molina-Portillo, Jone M. Altzibar, Lluís CireraEva Ardanaz, Kay Tee Khaw, Nicholas J. Wareham, Timothy J. Key, Ruth C. Travis, Christina Bamia, Philippos Orfanos, Antonia Trichopoulou, Domenico Palli, Valeria Pala, Rosario Tumino, Paolo Vineis, Salvatore Panico, H. Bas Bueno-de-Mesquita, W. M Monique Verschuren, Ellen A. Struijk, Petra H. Peeters, Gunnar Engström, Olle Melander, Malin Sund, Elisabete Weiderpass, Guri Skeie, Eiliv Lund, Teresa Norat, Marc Gunter, Elio Riboli, Paul Brennan

Research output: Contribution to journalArticlepeer-review


Background: Life expectancy is increasing in Europe, yet a substantial proportion of adults still die prematurely before the age of 70 years. We sought to estimate the joint and relative contributions of tobacco smoking, hypertension, obesity, physical inactivity, alcohol and poor diet towards risk of premature death. Methods: We analysed data from 264,906 European adults from the EPIC prospective cohort study, aged between 40 and 70 years at the time of recruitment. Flexible parametric survival models were used to model risk of death conditional on risk factors, and survival functions and attributable fractions (AF) for deaths prior to age 70 years were calculated based on the fitted models. Results: We identified 11,930 deaths which occurred before the age of 70. The AF for premature mortality for smoking was 31 % (95 % confidence interval (CI), 31-32 %) and 14 % (95 % CI, 12-16 %) for poor diet. Important contributions were also observed for overweight and obesity measured by waist-hip ratio (10 %; 95 % CI, 8-12 %) and high blood pressure (9 %; 95 % CI, 7-11 %). AFs for physical inactivity and excessive alcohol intake were 7 % and 4 %, respectively. Collectively, the AF for all six risk factors was 57 % (95 % CI, 55-59 %), being 35 % (95 % CI, 32-37 %) among never smokers and 74 % (95 % CI, 73-75 %) among current smokers. Conclusions: While smoking remains the predominant risk factor for premature death in Europe, poor diet, overweight and obesity, hypertension, physical inactivity, and excessive alcohol consumption also contribute substantially. Any attempt to minimise premature deaths will ultimately require all six factors to be addressed.

Original languageEnglish
Article number87
JournalBMC Medicine
Issue number1
Publication statusPublished - Jun 14 2016


  • Absolute risk
  • Attributable fraction
  • Modifiable risk factors
  • Mortality
  • Premature death

ASJC Scopus subject areas

  • Medicine(all)


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