The root causes of socioeconomic differentials in cancer and cardiovascular mortality in Greece Androniki Naska a,b , Michail Katsoulis a,b , Dimitrios Trichopoulos b,c,d and Antonia Trichopoulou a,b Lower socioeconomic groups experience higher rates of premature mortality in comparison with the upper socioeconomic groups. We have undertaken a study in Greece to assess socioeconomic differentials in overall, cancer, and cardiovascular (CVD) mortality and to identify their possible roots, using educational attainment to indicate socioeconomic status. Among participants in the general population, the Greek European Prospective Investigation into Cancer and Nutrition cohort, 23 697 individuals with no prevalent cancer or CVD disease at enrollment and with complete information on education and established or likely mortality risk factors, were followed up for an average of 9.6 years. Age-adjusted odds ratios of the prevalence of risk factors by education and sex were calculated through logistic regression and mortality ratios were estimated through Cox regression. With respect to overall and CVD mortality, the results indicated a 50% to more than 100% difference between the extreme categories of educational attainment. No gradient was, however, observed in cancer mortality. Obesity, poor diet, hypertension, and low physical activity were more prevalent among the least educated participants, but smoking was almost as common among the more and the less educated men and strikingly more common among the higher educated women. Likely intermediates did not explain more than one-third of the excess mortality among the less educated persons. In the Greek population, strong socioeconomic gradients were observed in the overall and CVD mortality, but not in cancer mortality. Established risk factors for premature mortality explained only a fraction of the observed gradients. European Journal of Cancer Prevention 21:490–496  c 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins. European Journal of Cancer Prevention 2012, 21:490–496 Keywords: education, European Prospective Investigation into Cancer and Nutrition, Greece, mortality, social class a WHO Collaborating Center for Food and Nutrition Policies, Department of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School, b Hellenic Health Foundation, c Bureau of Epidemiologic Research, Academy of Athens, Athens, Greece and d Department of Epidemiology, Harvard School of Public Health, Boston, USA Correspondence to Androniki Naska, PhD, WHO Collaborating Center for Food and Nutrition Policies, Department of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School, 75 Mikras Asias Str., Athens 115 27, Greece Tel: +30 210 746 2106; fax: +30 210 746 2079; e-mail: anaska@nut.uoa.gr Received 20 October 2011 Accepted 20 October 2011 Introduction In Greece, all-cause mortality rates are relatively low. In 2009, the annual age-standardized overall mortality rates were 693 deaths per 100 000 males and 473 deaths per 100 000 females, whereas in the same year, the European Union overall mortality rates were 1170 and 647 deaths per 100 000 males and females, respectively (World Health Organization Regional Office for Europe, 2011). Health and life expectancy are known to be closely linked to the country’s socioeconomic conditions. A number of studies indicate that lower socioeconomic groups, defined by educational attainment, occupational class, income, material possessions, or a combination of the above, experience higher rates of premature death in comparison with upper socioeconomic groups (Pekkanen et al., 1995; Smith et al., 1997; World Health Organization, 2008). Socioeconomic differentials in cardiovascular (CVD) mortality are often cited as the driving force behind socioeconomic differences in overall mortality (Pekkanen et al., 1995; Wong et al., 2002; Mackenbach et al., 2003). Studies report that mortality rates from respiratory or gastrointestinal diseases (including liver cirrhosis), in- juries and cancers of the lung, stomach, uteri, and cervix are also higher among individuals lower in the socio- economic hierarchy as compared with those higher up (Faggiano et al., 1997; Wong et al., 2002; Galea et al., 2011). Social determinants of health have been reported to include unemployment or job insecurity, early environ- mental exposures including inadequate parental support, addictions to tobacco, alcohol, or euphoric drugs, stress at work or in everyday life, dietary intakes, type of transport available, poverty, discrimination, social exclusion, and lack of social support networks (World Health Organiza- tion, 2008). In the present analysis, we aim to explore the roots of socioeconomic differentials in the overall, cancer, and CVD mortality rates of a large Greek general population cohort: the Greek European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. Materials and methods The European Prospective Investigation into Cancer and Nutrition Greece Study The study sample included apparently healthy volunteers (men and women) 20–86 years old, recruited from 1994 to 1999 around Greece in order to participate in EPIC. EPIC is a prospective cohort study, conducted in 23 490 Research paper 0959-8278  c 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI: 10.1097/CEJ.0b013e32834ef1bc Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.