Changes over 15 years in the contribution of adiposity and smoking to deaths in England and Scotland

BMC Public Health. 2021 Feb 11;21(1):169. doi: 10.1186/s12889-021-10167-3.


Background: For many years smoking has been the major threat to public health in developed countries. However, smoking prevalence has declined over a period when adiposity has increased. The aim of this study was to determine whether adiposity now accounts for more deaths than smoking in the general population as a whole or sub-groups of it.

Methods: This is a comparative risk assessment study using Health Surveys for England and Scottish Health Surveys from 2003 to 2017. Annual prevalence of overweight, obesity, current and former smoking were obtained and combined using population-based weights. Sex-specific risk ratios for all-cause mortality were obtained from the most recently published meta-analyses. Population attributable fractions across yeas were then estimated.

Findings: Overall, deaths attributable to current/former smoking declined from 23.1% (95% CI 20.6-25.8%) in 2003 to 19.4% (95% CI 17.3-21.6%) in 2017, whilst those attributable to adiposity (overweight or obesity) increased from 17.9% (95% CI 17.3-18.4%) in 2003 to 23.1% (95% CI 22.3-23.8%) in 2017 with cross-over occurring in 2013. Cross-over occurred earlier in men (2011) than women (2014). It occurred in 2006 for those aged over 65 years of age and in 2012 for those aged 45-64 years. Below 45 years, smoking remained the larger contributor to mortality.

Interpretation: Adiposity now accounts for more deaths in England and Scotland than smoking among people in middle- and old-age. National strategies to address adiposity should be a public health priority.

Keywords: Adiposity; Mortality; Obesity; Population attributable fraction; Smoking.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adiposity*
  • Aged
  • England / epidemiology
  • Female
  • Humans
  • Male
  • Middle Aged
  • Obesity* / epidemiology
  • Risk Factors
  • Scotland / epidemiology
  • Smoking / epidemiology