Abstract

SummaryBackgroundIncreasing premature mortality among some groups of Americans has been largely driven by increases in drug poisoning deaths. However, to our knowledge, a formal descriptive study by race and ethnicity, socioeconomic status, rurality, and geography has not been done. In this study, we examined US trends in premature all-cause and drug poisoning mortality between 2000 and 2015 at the county level among white, black, and Latino people.MethodsWe used US mortality data for the period Jan 1, 2000, to Dec 31, 2015, including underlying cause of death and demographic data, collected from death certificates by the Centers for Disease Control and Prevention National Center for Health Statistics, and ascertained county attributes from the 2011–15 Census American Community Survey. We categorised counties into quintiles on the basis of the percentage of people unemployed, the percentage of people with a bachelor’s degree, median income, and rurality. We estimated premature (ie, deaths in those aged 25–64 years) age-standardised mortality for all causes (by race and ethnicity) and drug poisoning, by county, for the periods of 2000–03 and 2012–15. We estimated annual percentage changes in mortality (2000–15) by county-level characteristics.FindingsPremature mortality declined from 2000–03 to 2012–15 among black and Latino people, but increased among white people in many US counties. Drug poisoning mortality increased in counties throughout the country. Significant increases between 2000 and 2015 occurred across low and high socioeconomic status and urban and rural counties among white people aged 25–64 years (annual percentage change range 4·56% per year [95% CI 3·56–5·57] to 11·51% per year [9·41–13·65]), black people aged 50–64 years (2·27% per year [0·42–4·16] to 9·46% per year [7·02–11·96]), Latino women aged 25–49 years (2·43% per year [1·18–3·71] to 5·01% per year [3·80–6·23]), and Latino men aged 50–64 years (2·42% per year [0·53–4·34] to 5·96% per year [3·86–8·11]). Although drug poisoning mortality increased rapidly in counties with the lowest socioeconomic status and in rural counties, most deaths during 2012–15 occurred in the largest metropolitan counties (121 395 [76%] in metropolitan counties with ≥250 000 people vs 2175 [1%] in the most rural counties), reflecting population size.InterpretationPremature mortality has declined among black and Latino people in the USA, and increased among white people, particularly in less affluent and rural counties. Increasing drug poisoning mortality was not limited to poor white people in rural areas. Rapid increases have occurred in communities throughout the USA regardless of race and ethnicity, socioeconomic status, or rurality. Widespread public health interventions are needed to addess this public health emergency.

Highlights

  • In 2016, life expectancy at birth in the USA decreased for the second year in a row, an unexpected trend for a highincome country.[1,2] These trends largely reflect increasing mortality among young and middle-aged white people over the past two decades, due in part to increases in drug poisonings, with additional contributions from suicide and chronic liver disease.[3,4] Premature mortality has increased substantially among American Indians and Alaska Natives, but declines in premature mortality occurred among black and Latino people and Asian and Pacific Islanders over the same period.[4]

  • Between 2000 and 2015, 9·5 million premature deaths occurred among people in the USA aged [25–64] years. 2 205 280 premature deaths occurred in the period of 2000–03 (1 555 690 in white people, 420 419 in black people, and 158 057 in Latino people), and 2 553 491 premature deaths occurred in the period of 2012–15 (1 775 231, 452 354, and 224 708, respectively)

  • When we examined the absolute number of deaths, 85 209 (53%) drug poisoning deaths occurred in metropolitan counties with populations greater than 1 million people and 36 186 (23%) occurred in counties with populations of 250 000–999 999 people, while only 2175 (1%) drug poisoning deaths occurred in completely rural areas

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Summary

Introduction

In 2016, life expectancy at birth in the USA decreased for the second year in a row, an unexpected trend for a highincome country.[1,2] These trends largely reflect increasing mortality among young and middle-aged white people over the past two decades, due in part to increases in drug poisonings, with additional contributions from suicide and chronic liver disease.[3,4] Premature mortality has increased substantially among American Indians and Alaska Natives, but declines in premature mortality occurred among black and Latino people and Asian and Pacific Islanders over the same period.[4] Mortality and life expectancy are known to vary substantially between and within US states,[4,5,6] with widening gaps reported in life expectancy between rich and poor Americans.[7,8,9] the effect of diverging national trends in premature mortality by race and ethnicity on county-level disparities in mortality is unclear. A common narrative surrounding recent increases in drug poisoning mortality often focuses on poor, rural, white Americans in regions of high un­ employment. Drug poisonings are high in rural counties with economic distress,[10] other data www.thelancet.com/public-health Vol 4 February 2019

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