Faltering survival improvements at young-middle ages in high-income English-speaking countries: population-level period and cohort analyses

Objective To quantify mortality trends in six high-income English-speaking countries (Australia, Canada, Ireland, New Zealand, UK, USA) - including by age, sex, period, cohort and major cause - and compare them with other high-income countries (HICs). Design Period and cohort analysis using population-level demographic data. Setting 6 high-income Anglophone countries and the average for 14 other HICs. Participants All-cause mortality data from the Human Mortality Database (1970-2021) and cause-specific death counts from the WHO Mortality Database (2017-19), disaggregated by sex, age group and major cause of death. Main outcome measures Trends in longevity measures (period life expectancy at birth, 0-50 years, and at age 50 years) and lifespan inequality were estimated for 1970-2021. The contribution of causes of death was measured by calculating life-years lost and decomposing differences in life expectancy between each Anglophone country and the average for other HICs in the pre-pandemic period. The impact of differential cohort survival on current differences in longevity was assessed by calculating the gap in truncated cross-sectional average length of life. Results Having improved consistently from the 1970s, life expectancy in all English-speaking countries except Ireland stalled in the pre-pandemic decade, mainly due to stagnating or increasing mortality at young-middle ages. Relative to other HICs, those born in Anglophone countries since the 1970s experienced relative mortality disadvantage, largely attributable to injuries, including suicides, substance-related and cardiovascular mortality. In contrast, older cohorts enjoyed advantages for females in Australia and Canada and for males in all Anglophone countries except the USA. Conclusions The striking disadvantage of young adults in English-speaking countries relative to other HICs should be seen as an emerging and avoidable threat to efforts to improve health equity. Population health policies should be adapted to meet this challenge. Post-pandemic mortality and life expectancy trends in Anglophone countries require further monitoring. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement V.C-R. and S.T. acknowledge support from the Australian Research Council (DP210100401). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study used ONLY openly available demographic data. We used the Human Mortality Database (https://www.mortality.org/) for all-cause mortality data, and the WHO Mortality Database (https://www.who.int/data/data-collection-tools/who-mortality-database) for cause-specific death counts. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors