PHSSR Policy Roadmaps for Acting Early on NCDs Synthesis Report 2025

33 Acting early on NCDs The Partnership for Health System Sustainability and ResilienceTobacco control successes mask persistent inequalities that concentrate smoking among vulnerable populations. Canada reduced smoking prevalence from 27.1% in 2000 to a projected 10.1% by 2025, but there remain significant disparities in smoking rates: 16% of adults in the lowest income quintile smoke compared to 8.3% in the highest, with rates in northern territories and several eastern provinces exceeding national averages (WHO, 2025g). Germany shows tobacco use in low and middle educational groups nearly double that in the high educational group (Robert Koch- Institut, 2024c). As of 2022, Italy maintained a 22.4% age adjusted rate of tobacco use (WHO, 2025g), despite comprehensive advertising bans since 1983, suggesting a need for a renewed emphasis on tobacco control and smoking cessation. Environmental and structural factors Environmental risk factors compound social disadvantage through differential exposure and vulnerability. France’s experience is particularly instructive: while air pollution causes approximately 48,000 deaths annually (Health Effects Institute, 2024), the most deprived areas have a ten-fold higher risk of being environmental hotspots, areas with cumulative exposure to heat, air pollutants, and lack of vegetation (Adélaïde et al., 2024). Critically, successful pollution reduction policies have disproportionately benefited high-income neighbourhoods, potentially widening rather than narrowing health disparities. Italy documents clear associations between air pollution exposure and respiratory cancer mortality, with northern industrial regions showing higher rates that affect working-class populations despite generally better healthcare infrastructure in these areas. Climate change amplifies these disparities: deaths from heatstroke in Japan increased five-fold from 1995 to 2023, with 83.3% among those aged 65 and older, a population that clusters in areas with limited cooling infrastructure and faces financial constraints in adapting to extreme temperatures (MHLW, 2023a; Zanobetti et al,. 2012). Rural and remote populations face compounding disadvantages that amplify NCD risk. Limited specialist access, long travel distances, and concentrated poverty create environments where risk factors flourish and early intervention remains inaccessible. Canada’s territories exhibit significantly higher mortality rates from both preventable and treatable causes compared to provinces (CIHI). Italy’s North-South divide produces 2–3 year life expectancy differences (WHO Regional Office for Europe, 2022), while France’s overseas territory Mayotte shows life expectancy 9 years below the best-performing regions (INSEE, 2025a). Socioeconomic gradients in risk factors Educational gradients demonstrate how early disadvantage compounds over time. Analysis in Japan between 2010 and 2015 revealed mortality disparities of up to 40% by educational background, with corresponding gradients by educational-level in smoking rates, dietary quality, and physical activity (Tanaka et al., 2024). France’s educational differences are associated with an 8-year life expectancy gap for men and a 5-year gap for women that has remained unchanged for three decades, suggesting that current interventions fail to interrupt the transmission of health disadvantage across generations. The poorest populations also face systematically higher disease risk: Germany’s lowest income quintile has 1.6 times higher likelihood of developing chronic illness compared to those in the highest (OECD, 2023a), while France’s poorest 10% are 1.4 times more likely to develop NCDs than the richest 10% (DREES, 2022). Disparities are also evident in access to healthcare. In Spain, a study in Catalonia found that patients from very low socioeconomic status (SES) groups waited longer for cancer surgeries – 3.5 days more for prostate cancer and 2.3 days more for colorectal cancer – compared to patients from low SES backgrounds within the same hospitals (Bosque-Mercader et al., 2023).