ORIGINAL ARTICLE Mortality by occupation-based social class in Italy from 2012 to 2014 Paola Bertuccio 1 • Gianfranco Alicandro 1,2 • Gabriella Sebastiani 2 • Nicolas Zengarini 3 • Giuseppe Costa 3 • Carlo La Vecchia 1 • Luisa Frova 2 Received: 25 February 2018 / Revised: 26 June 2018 / Accepted: 19 July 2018 Ó Swiss School of Public Health (SSPH+) 2018 Abstract Objectives Evaluating socio-economic inequality in cause-specific mortality among the working population requires large cohort studies. Through this census-based study, we aimed to quantify disparities in mortality across occupation-based social classes in Italy. Methods We conducted a historical cohort study on a sample of more than 16 million workers. We estimated the mortality rate ratios for each social class, considering upper non-manual workers as reference. Results Non-skilled manual workers showed an increased mortality from upper aero-digestive tract, stomach and liver cancers, and from diseases of the circulatory system, transport accidents and suicides in both sexes, and from infectious diseases, diabetes, lung and bladder cancers only in men. Among women, an excess mortality emerged for cervical cancer, whereas mortality from breast and ovarian cancers was lower. When education was taken into account, the excess mortality decreased in men while was no longer significant in women. Conclusions There are remarkable disparities across occupation-based social classes in the Italian working population that favour the upper non-manual workers. Our data could be useful in planning policies for a more effective health and social security system. Keywords Socio-economic inequality Á Occupation Á Census Á Mortality Introduction Low socio-economic position is a recognized risk factor for premature mortality from several causes (Mackenbach et al. 2008; Regidor et al. 2016; de Gelder et al. 2017). Multiple mechanisms are involved in the pattern linking low socio-economic position to premature mortality, including risky lifestyle behaviours, reduced access to screening programs, diagnostic procedures and effective treatments, along with psychosocial factors such as stress, depression, financial difficulties, limited social network and low job control, besides possible occupational expo- sures (Galobardes et al. 2006a). Occupation-based social classes along with education are the major markers of social standing used in studies investigating socio-economic disparities in health (Galo- bardes et al. 2006a, b). Two previously published studies found that education is a main determinant of premature mortality in Italy for a wide range of causes with, however, important sex differences, especially when considering cancer mortality (Alicandro et al. 2017, 2018). Although education and occupation are correlated, they cannot be used interchangeably as they measure different phenomena and act through different mechanisms (Geyer 2006). While education reflects the ability of the individual to turn information into practical measures and behaviours, occupation better indicates prestige, job control and imbalance of effort and reward. All these mechanisms are involved in the generation of socio-economic disparities in health and are expected to have different roles in the Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00038-018-1149-8) contains supplementary material, which is available to authorized users. & Gianfranco Alicandro gianfranco.alicandro@unimi.it 1 Department of Clinical Sciences and Community Health, Universita ` degli Studi di Milano, Via Vanzetti 5, 20133 Milan, Italy 2 Italian National Institute of Statistics, Rome, Italy 3 Epidemiology Unit, ASL TO3 Piedmont Region, Grugliasco, TO, Italy 123 International Journal of Public Health https://doi.org/10.1007/s00038-018-1149-8