Explaining the Widening Divides in US Midlife Mortality: Is There a Smoking Gun?

The education-mortality gradient has increased sharply in the last three decades, with the life-expectancy gap between people with and without a college degree widening from 2.6 years in 1992 to 6.3 years in 2019 (Case and Deaton 2023). During the same period, mortality inequality across counties rose 30 percent, accompanied by an increasing rural health penalty. Using county- and state-level data from the 1992–2019 period, we demonstrate that these three trends arose due to a fundamental shift in the geographic patterns of mortality among college and non-college populations. First, we find a sharp decline in both mortality rates and geographic inequality for college graduates. Second, the reverse was true for people without a college degree; spatial inequality became amplified. Third, we find that rates of smoking play a key role in explaining all three empirical puzzles, with secondary roles attributed to income, other health behaviors, and state policies. Less well-understood is why “place effects” matter so much for smoking (and mortality) for those without a college degree.