Changes in life expectancy in Aotearoa New Zealand: a cause-specific decomposition analysis over 20 years

In Aotearoa New Zealand, life expectancy, a broad indicator of overall population health, has increased over the past two decades.¹ Between 2001 and 2023, life expectancy increased by 4.3 years in New Zealand, exceeding the gains observed in Australia, the United Kingdom (UK) and the United States of America (USA). Over the most recent decade, gains in life expectancy in New Zealand (1.5 years) were larger than those seen in Australia (0.8 years), while the UK and the USA experienced small net declines.¹ More recently, in the early years of the COVID-19 pandemic, New Zealand was one of only a few countries where life expectancy remained unchanged or increased.² Examining how different health conditions have contributed to gains in life expectancy across population groups provides an opportunity to understand changes in mortality patterns in a more detailed and context-specific way. Previous work has described ethnic-specific life expectancy gaps, including potentially avoidable mortality and smoking, and their contributions to ethnic gaps in life expectancy.^3,4 However, to our knowledge, no study has applied a cause-specific decomposition to estimate how changes in mortality from individual causes have shaped overall life expectancy gains by ethnic group in the New Zealand population.

Life expectancy decomposition methods provide a structured approach for attributing changes in life expectancy to age- and cause-specific mortality patterns. The method developed by Arriaga separates total change in life expectancy into additive components representing the contribution of each age group and cause of death.⁵ This approach enables identification of conditions where changes in mortality have contributed most to increases or decreases in life expectancy and provides a framework for interpreting how changes in risk factors, prevention, diagnosis and treatment may have shaped mortality trends over time. The Arriaga method has been widely applied in population health research examining life expectancy change.^3,4,6–8

This study applies Arriaga’s decomposition method to national mortality data to quantify the causes of death that have contributed to life expectancy gains in New Zealand between the periods 2001–2003 and 2020–2022. The aim is to identify the major drivers of change in life expectancy across ethnic and sex groups and to improve understanding of the conditions contributing to both population health gains and persistent inequities.

Methods

Non-identifiable mortality data for all registered deaths in New Zealand were obtained from the New Zealand Mortality Collection⁹ for the aggregated periods of 2001–2003 and 2020–2022. Population estimates for the corresponding periods, stratified by age group, sex and prioritised ethnicity, were sourced from Statistics New Zealand, with ethnicity derived from the New Zealand census. Three-year aggregated periods were used to stabilise mortality rates, reduce the influence of year-to-year variation and minimise potential impacts arising from delayed coronial coding of deaths. Ethnicity information in the Mortality Collection was as recorded on the certificate of death and allows multiple responses. For individuals with more than one ethnicity, a prioritisation process was applied to categorise each person into non-overlapping categories. The process prioritised ethnicity into Māori, Pacific peoples, Asian peoples and European and Other groupings following Health Information Standards Organisation 10001:2017 protocols.¹⁰ While prioritisation is helpful for categorising ethnicity into non-overlapping groups, it can result in undercounting and misclassification of some groups, which may result in under-estimates of the mortality burden of some populations, particularly Pacific peoples.^11,12

Two approaches to cause of death decomposition were undertaken: a broad category approach and a more detailed individual cause approach. For the broad category approach, underlying causes of death, coded using the International Classification of Diseases (ICD), Tenth Revision (ICD-10), were grouped into 10 broad and mutually exclusive cause categories for decomposition analyses. These were defined as follows: cardiovascular diseases (I00–I99); cancers (C00–C97, D45–D47); endocrine, metabolic and nutritional disorders (E00–E90); respiratory diseases (J00–J99); neurological and mental disorders (F00–F99, G00–G99); digestive diseases (K00–K93); genitourinary diseases (N00–N99); infections (A00–B99); external causes (injuries; V00–Y89); and a residual category of “other” causes. The residual “other” causes category captured deaths not assigned to the specified groupings, representing a heterogeneous set of other and less-common causes. The second, more detailed approach grouped deaths into the 50 most-common causes, comprising specific conditions, including individual cancers and cardiovascular subtypes, as well as broader groupings across neurological, renal, respiratory, infectious and external causes, with residual categories within major disease domains included to capture heterogeneous causes not otherwise classified.

Life expectancy at birth was calculated for each sex and ethnic group for the 3-year aggregated periods of 2001–2003 and 2020–2022 using standard abridged period life table methods. Age intervals comprised age 0, 1 to 4 years, followed by five-year age groups, with 90 years and older as the open-ended final age group. Changes in life expectancy between these two periods were disaggregated into broad cause-of-death categories, as well as more granular individual causes. Their specific contributions to the overall change in life expectancy were estimated using the method developed by Arriaga.⁵ This approach expresses the total change in life expectancy as the sum of contributions from changes in mortality by age and cause, allowing identification of conditions and age groups contributing to increases or decreases in life expectancy.

Deaths attributed to COVID-19 were retained within the cause-specific classification to ensure a complete representation of mortality in the later period. However, given the absence of COVID-19 in the baseline period and the focus of this study on longer-term changes in major causes of mortality, COVID-19 is not emphasised in the primary results but is presented in tables for completeness.

This study was considered low risk and was out of scope for Health and Disability Ethics Committee review as it used de-identified administrative health data. Locality authorisation including Māori research review was granted by Health New Zealand – Te Whatu Ora Waitematā District, Research & Knowledge Centre (approval code: WAI20538).

Results

Across all ethnic and sex groups, life expectancy increased between the periods 2001–2003 and 2020–2022. The largest absolute gains were observed among Māori, while smaller increases were seen among Asian and European and Other populations where baseline life expectancy was already higher (Figure 1). Improvements were driven primarily by reductions in mortality at ages 45 years and older. Across all populations, declines in cardiovascular disease and cancer mortality contributed the largest share of the gains in life expectancy.

Māori males

Life expectancy at birth for Māori males increased from 69.4 years in 2001–2003 to 74.6 years in 2020–2022, an increase of 5.2 years. Gains were primarily driven by reductions in mortality among those aged 65 years and older, with additional contributions from ages 45–64 years (Figure 4). Reductions in cardiovascular disease mortality contributed the largest share of gains (Figure 2), particularly from ischaemic heart disease, which contributed approximately 1.9 years, and cerebrovascular disease (Table 1). Reductions in mortality from diabetes, lung cancer and chronic obstructive pulmonary disease each contributed to the increase in life expectancy of approximately 0.5 years. Smaller increases were observed from reductions in mortality from other cancers and motor vehicle accidents. In contrast, increases in mortality from Alzheimer’s disease and related dementias contributed to decreases in life expectancy.

Māori females

Life expectancy at birth for Māori females increased from approximately 73.9 years in 2001–2003 to 78.6 years in 2020–2022, an increase of around 4.7 years. Gains were primarily driven by reductions in mortality among those aged 65 years and older, with additional contributions from ages 45–64 years (Figure 5). Reductions in cardiovascular disease mortality contributed the largest share of gains (Figure 3), particularly from ischaemic heart disease, which contributed approximately 1.7 years, and cerebrovascular disease, which contributed around 0.5 years. Reductions in mortality from diabetes contributed substantially to increases in life expectancy, at approximately 0.6 years. Reductions in cancer mortality also contributed to increases in life expectancy, particularly for lung cancer and breast cancer, each contributing around 0.4 years. Additional increases were observed from reductions in mortality from chronic obstructive pulmonary disease. These increases were partly offset by increases in mortality from Alzheimer’s disease and related dementias, which contributed to decreases in life expectancy.

View Table 1–4, Figure 1–5.

Pacific males

Life expectancy at birth for Pacific males increased from approximately 72.0 years in 2001–2003 to 75.4 years in 2020–2022, an increase of around 3.4 years. Gains were primarily driven by reductions in mortality among those aged 65 years and older, with smaller contributions from ages 45–64 years. Reductions in cardiovascular disease mortality contributed the largest share of gains, with ischaemic heart disease contributing approximately 1.4 years and cerebrovascular disease around 0.5 years (Table 2). Reductions in chronic obstructive pulmonary disease mortality contributed to the increase in life expectancy. Smaller increases were observed for prostate cancer, motor vehicle accidents and lung cancer. In contrast, increases in mortality from Alzheimer’s disease and related dementias, and metabolic and nutritional diseases, contributed to decreases in life expectancy.

Pacific females

Life expectancy at birth for Pacific females increased from approximately 76.6 years in 2001–2003 to 79.1 years in 2020–2022, an increase of around 2.5 years. Gains were primarily driven by reductions in mortality among those aged 65 years and older, with smaller contributions from ages 45–64 years. Reductions in cardiovascular disease mortality contributed the largest share of gains, particularly from ischaemic heart disease, which contributed approximately 1.1 years, and cerebrovascular disease, which contributed around 0.8 years. Additional contributions to the increase in life expectancy were observed from reductions in mortality from chronic obstructive pulmonary disease and several cancers, including ovarian cancer, non-Hodgkin lymphoma, brain and central nervous system cancer and liver cancer. A reduction in mortality and therefore increase in life expectancy was observed for most cancers; however, uterine cancer was an exception, with increasing mortality contributing to a small net decrease in life expectancy. Small net decreases were also associated with increases in mortality from Alzheimer’s disease and related dementias, and the residual other causes category.

Asian males

Life expectancy at birth for Asian males increased from approximately 83.6 years in 2001–2003 to 86.5 years in 2020–2022, an increase of around 2.9 years. Gains were primarily driven by reductions in mortality among those aged 65 years and older, with smaller contributions from ages 45–64 years. Reductions in cardiovascular disease mortality contributed the largest share of gains, with ischaemic heart disease contributing approximately 1.2 years and cerebrovascular disease around 0.4 years (Table 3). Reductions in mortality from prostate cancer and chronic obstructive pulmonary disease also contributed to the increase in life expectancy, contributing approximately 0.6 and 0.5 years, respectively. Smaller increases were observed from declines in mortality from diabetes, motor vehicle accidents, lung cancer and liver cancer. In contrast, increases in mortality from Alzheimer’s disease and related dementias, other forms of heart disease, other respiratory conditions and falls contributed to decreases in life expectancy.

Asian females

Life expectancy at birth for Asian females increased from approximately 86.1 years in 2001–2003 to 89.2 years in 2020–2022, an increase of around 3.1 years. Gains were primarily driven by declines in mortality among those aged 65 years and older, with smaller contributions from ages 45–64 years. Reductions in cardiovascular disease mortality contributed the largest share of gains, with ischaemic heart disease and cerebrovascular disease contributing approximately 1.6 and 1.3 years, respectively. Additional contributions to the increase in life expectancy were observed from declines in mortality from chronic obstructive pulmonary disease, pneumonia and diabetes. Smaller increases were also observed from reductions in mortality from motor vehicle accidents, the residual other causes category and selected cancers. These increases were partly offset by increases in mortality from Alzheimer’s disease and related dementias, which contributed approximately a 0.7-year decrease in life expectancy, as well as smaller decreases associated with pancreatic cancer, falls and hypertensive diseases.

European and Other males

Life expectancy at birth for European and Other males increased from approximately 77.5 years in 2001–2003 to 81.1 years in 2020–2022, an increase of around 3.6 years. Gains were primarily driven by reductions in mortality among those aged 65 years and older, with smaller contributions from ages 45–64 years. Declines in cardiovascular disease mortality contributed the largest share of gains, with ischaemic heart disease contributing approximately 1.4 years and cerebrovascular disease around 0.4 years (Table 4). Additional contributions to the increase in life expectancy were observed from declines in mortality from chronic obstructive pulmonary disease, lung cancer, colorectal cancer and other cancers. Smaller increases were also observed from reductions in mortality from motor vehicle accidents, the residual other causes category, prostate cancer and aortic aneurysm and dissection. In contrast, increases in mortality from Alzheimer’s disease and related dementias contributed to decreases in life expectancy.

European and Other females

Life expectancy at birth for European and Other females increased from approximately 82.0 years in 2001–2003 to 84.6 years in 2020–2022, an increase of around 2.6 years. Gains were primarily driven by declines in mortality among those aged 65 years and older, with smaller contributions from ages 45–64 years. Reductions in cardiovascular disease mortality contributed the largest share of gains, particularly from ischaemic heart disease, which contributed approximately 1.2 years, and cerebrovascular disease, which contributed around 0.6 years. Additional increases in life expectancy were observed from declines in mortality from breast cancer, chronic obstructive pulmonary disease and colorectal cancer. Smaller increases were also observed from declines in mortality from motor vehicle accidents, the residual other causes category, lung cancer, ovarian cancer, pneumonia and heart failure. These increases were partly offset by increases in mortality from Alzheimer’s disease and related dementias, other forms of heart disease and falls, which contributed to decreases in life expectancy.

Discussion

Life expectancy improved for all ethnic and sex groups over the study period. Māori experienced larger gains than the European and Other population, resulting in a narrowing of the life expectancy gap for both males and females. Pacific peoples also experienced improvements in life expectancy, but these were similar to those for the European and Other population, and the gap remained largely unchanged.

Across all groups, reductions in cardiovascular and cancer mortality accounted for more than half of the total improvement in life expectancy, reflecting their larger contribution to adult mortality. Declines in cardiovascular mortality likely reflect a combination of long-term declines in smoking, improvements in population-level cardiovascular risk factors, advances in primary and secondary prevention, including wider use of antihypertensive therapy, lipid-lowering medications and improved acute and post-acute management of ischaemic heart disease and stroke.^13,14 These factors are consistent with previously documented declines in cardiovascular mortality in New Zealand and other high-income countries over similar periods.^13,15 However, there are recent reports that these declines may have stalled, and there is evidence of widening rates of acute coronary syndrome among Māori and Pacific peoples compared with Europeans.¹⁶

Reductions in cancer mortality, particularly lung cancer and breast cancer, were large contributors to life expectancy gains among Māori. The contribution from lung cancer likely reflects declines in smoking prevalence over the past decades, following the implementation of tobacco-control policies, increased cessation support and declining uptake of smoking among younger cohorts.^17,18 New Zealand has experienced one of the largest declines in smoking prevalence among high-income countries,¹⁹ with adult daily smoking falling from around 30% in 2000 to approximately 8% in 2024.²⁰ However, important inequities remain. Smoking prevalence among Māori remains about 17%, whereas prevalence among European and Asian populations is now around or below 6%.²⁰

The contribution of lung cancer to life expectancy gains among Māori females is consistent with historically higher smoking prevalence and later peaks in tobacco-related mortality in this group, reflecting well-described cohort effects in smoking-related disease.^3,21,22 In contrast, lung cancer contributed less to life expectancy gains among Asian populations, where smoking prevalence has historically been lower and there are potentially effects of different disease profiles, for example non-smokers often have been shown to have less invasive disease.^3,23,24 Future improvements in early-stage diagnosis and survival for people with lung cancer may come through lung cancer screening.²⁵ Simulation modelling in New Zealand has shown that it will likely be cost effective, as well as providing improvements to overall population health.²⁶ Work is underway to directly inform the development of an equitable lung cancer screening programme and establish the parameters to plan for the downstream impacts of the screening pathway, including increasing early-stage diagnosis and managing actionable incidental findings.²⁷ In parallel, recent expansion of access to systemic therapies, including immunotherapy and targeted treatments, would be expected to further improve survival for people diagnosed with lung cancer.²⁸ Ensuring equitable access to these treatments across population groups will be important for sustaining declines in lung cancer mortality and avoiding widening existing inequities. Finally, the emergence of nicotine products such as e-cigarettes (vaping) and heated tobacco introduces two related sources of uncertainty. First, their health effects remain uncertain, with emerging evidence suggesting potential associations of vaping with adverse respiratory and cardiometabolic outcomes, and some emerging evidence on potential cancer risks, although evidence on longer-term outcomes remains limited.^29–31 Second, the impact of nicotine products on future smoking patterns and cessation behaviours is not yet known and may influence trajectories in lung cancer incidence as well as other smoking-related conditions. Further uncertainties have also been highlighted with changes to New Zealand’s Smokefree legislation and recent data indicating that declines in smoking prevalence may have plateaued.^32–34

Some cancers have shown an increasing incidence over recent times. In particular, the rising incidence of uterine cancer, predominantly endometrial cancer, has been reported in New Zealand.³⁵ This increase is more pronounced among Pacific women than other ethnic groups.³⁶ The contribution of uterine cancer to changes in life expectancy among Pacific females was one of only a very small number of cancers across all groups that resulted in a net loss in life expectancy. Uterine cancer among Pacific females may have implications for future life expectancy trends if the rising incidence is not accompanied by continued improvements in early detection and survival.

Declining mortality rates for diabetes and other endocrine and metabolic conditions made contributions to life expectancy gains among Māori and Pacific peoples, consistent with higher prevalence of diabetes and related cardiovascular complications in these populations.³⁷ Improvements may reflect better detection and management among people with diabetes, resulting in improved survival. The continued prominence of these conditions indicates their ongoing role in shaping ethnic inequities in mortality and life expectancy and reflects long-standing inequities in both the burden of disease and in diabetes management.^4,38 With the prevalence of diabetes projected to continue to rise over the coming decades,³⁹ the immediate impact of diabetes as well as the associated burden of comorbidities, including cardiovascular and renal disease, has the potential to influence mortality patterns and future life expectancy trajectories.

Most gains in life expectancy were attributable to declines in mortality at adult and older ages, rather than changes in early life mortality. This pattern is reflected in the contributions of cardiovascular diseases, cancer, diabetes and chronic respiratory disease across all ethnic groups, and in the greater sensitivity of life expectancy estimates to mortality change at working and early older ages. This finding should not be interpreted as implying that population health gains are best achieved through interventions focussed predominantly on older adults. Māori and Pacific populations have younger age structures, and strategies centred on later-life alone may therefore have limited equity impact. Interventions targeting early life and younger age groups remain critical because improvements in these periods influence health trajectories across the life course and support more equitable long-term gains in life expectancy.

The broad improvements in life expectancy between the periods 2001–2003 and 2020–2022 are consistent with sustained declines in mortality from major non-communicable diseases in New Zealand over recent decades.¹⁵ The magnitude of gains varied by ethnicity and sex, with Māori experiencing the largest absolute increases. Despite overall progress, Māori and Pacific life expectancy remained substantially lower than that of Asian and European and Other populations in both periods, indicating that long-standing ethnic inequities in survival have persisted alongside population-level health gains.

Based on current trajectories, closing the remaining life expectancy gaps for both Māori and Pacific peoples will require sustained effort over several decades. Given the large contribution of cardiovascular disease and cancer to life expectancy change, and their role in driving persistent inequities,⁴ these conditions represent the areas with the greatest potential for future gains, particularly where reductions can be achieved equitably across population groups. Achieving further progress will require strengthening prevention and risk-factor reduction, earlier diagnosis, improved participation in screening and early detection programmes and more equitable access to timely and high-quality treatment. In the cancer context, this includes continued attention to stage at diagnosis, access to diagnostic pathways, treatment timeliness and equity in survival outcomes. For cardiovascular disease, earlier identification and management of hypertension, diabetes and other risk factors remains important. Reducing inequities across both disease areas will depend not only on improvements in overall care, but on equitable access, quality, continuity and outcomes across the care pathway. These efforts will also need to be supported by action on the structural determinants that shape patterns of risk, access to services and continuity of care, including income, housing, education, employment and broader features of the social and policy environment.

Analysing life expectancy by disease provides useful insight into the drivers of mortality change, but these findings should be interpreted within the broader context of systemic factors and the social determinants of health. Focussing only on disease-specific outcomes risks overlooking the wider structural conditions that shape patterns of risk, access to services and continuity of care. Interpretation of life expectancy trends therefore needs to extend beyond individual-level interventions to consider the broader health and social systems in which these patterns occur, including the role of primary prevention, equitable access to screening and early detection programmes and the structural determinants that influence exposure to risk and engagement with health services.

These findings have implications for understanding health equity in New Zealand. While overall life expectancy increased for all groups, persistent ethnic differences indicate that these gains have not eliminated long-standing inequities, and convergence remains some way off. The contribution of cardiovascular diseases, diabetes and smoking-related conditions among Māori and Pacific peoples suggests that inequities in exposure to risk factors, access to preventive care and outcomes following diagnosis remain important drivers of mortality differences. These results reinforce the continued importance of equity-focussed approaches to prevention and chronic disease management alongside broader population-level strategies.

Strengths

This study has several strengths. It uses national mortality data with near complete population coverage, minimising selection bias and supporting robust comparisons over time. The application of a well-established life expectancy decomposition method allows changes in overall life expectancy to be attributed to cause-specific mortality changes, providing greater interpretability than analyses based solely on all-cause mortality trends. The use of two time periods widely spaced across two decades enables assessment of long-term changes in mortality patterns, rather than short-term fluctuations.

The ability to examine results by ethnicity and sex provides a detailed description of how mortality improvements have differed across population groups. This approach supports equity-focussed monitoring by identifying both shared and divergent drivers of life expectancy change, and by highlighting causes that have contributed most to persistent differences in life expectancy.

Limitations

Several limitations should be acknowledged, both in the underlying analysis and in life expectancy as a measure. Life expectancy is a widely used summary measure of population health, but it has important limitations that constrain its interpretation as a comprehensive indicator of wellbeing. It captures length of life rather than quality, and therefore does not reflect time lived with disability, chronic illness or reduced functioning, which are more directly assessed using measures such as healthy life expectancy, Disability-Adjusted Life Years or Quality-Adjusted Life Years. Life expectancy is also relatively insensitive to short-term changes in health systems or public health interventions, as it reflects long-term mortality patterns that evolve slowly over time. It does not directly measure access to, or quality of, healthcare, nor does it adequately capture the burden of non-fatal conditions that substantially affect quality of life. In addition, life expectancy is shaped by broader social, economic and historical determinants, including education, housing and discrimination, which are not explicitly represented in the metric itself. The individualistic framing of life expectancy further limits its cultural relevance, particularly in New Zealand, where Māori and other Indigenous health perspectives emphasise collective, holistic and relational dimensions of wellbeing that extend beyond individual survival.

Cause-of-death data are subject to misclassification and changes in coding practices over time, which may affect the attribution of deaths to specific causes and, in turn, the estimated contributions to life expectancy change. The analysis relies on the accuracy of the underlying (primary) cause of death recorded on the death certificate and does not account for contributing or multiple causes of death. This is particularly relevant for conditions such as diabetes, chronic respiratory disease and cardiovascular diseases, which frequently coexist and may act as contributing rather than underlying causes, potentially leading to under-estimation of their contribution to mortality change.

The use of prioritised ethnicity, while consistent with national reporting standards for health statistics, may obscure the experiences of people who identify with multiple ethnic groups. This is particularly relevant for Pacific peoples, where prioritisation can under-estimate mortality compared with a total response approach. In the present analysis, the magnitude of this effect appears small based on comparisons of mortality counts, with approximately 3% of deaths involving a Pacific ethnic group affected by prioritisation. In addition, population denominator data corresponding to the study periods were not available by total response ethnicity, age group and sex, which limited the ability to implement a total response approach in this analysis.

The broad Level 1 ethnicity groupings used in this analysis may mask important heterogeneity within Asian and Pacific populations. More detailed disaggregation, for example by Chinese, Indian and other Asian groups, or by specific Pacific sub-groups such as Samoan, Tongan and Cook Islands Māori, would provide a clearer understanding of potential differences in mortality patterns. In addition, undercounting of certain population groups is a recognised limitation in health data in New Zealand, especially among those who are Māori or who identify with multiple ethnicities which has been shown to lead to misclassification.^11,12,40

The decomposition approach used here is descriptive and based on underlying causes of death. It does not independently quantify the contribution of changes in socio-economic conditions, access to or quality of health care, or risk-factor exposures beyond those captured in observed cause-specific mortality patterns. The analysis is also limited to underlying causes of death and therefore reflects only fatal disease burden. Data gaps among certain groups further restrict the scope of analysis, for example among disabled populations.

The later comparison period includes the COVID-19 pandemic, which may have influenced cause-specific mortality patterns. Deaths attributed to COVID-19 were included in the decomposition as part of the observed mortality experience in the later period. As COVID-19 was not present in the baseline period, its contribution reflects the emergence of a new cause of death rather than a change in an existing cause. It is retained to ensure a complete representation of cause-specific mortality. In addition, at the time of data extraction, a small number of 2022 deaths remained subject to coronial investigation, which may have affected cause-of-death classification, most likely among deaths classified as external causes. The analysis used aggregated 3-year periods to reduce the influence of short-term fluctuations arising from the pandemic and from deaths that were still under coronial investigation in 2022.

Conclusion

Life expectancy at birth increased across all ethnic and sex groups in Aotearoa New Zealand between the periods 2001–2003 and 2020–2022, largely driven by reductions in cardiovascular and cancer mortality. Māori experienced larger gains than the European and Other population, resulting in some narrowing of the life expectancy gap, whereas the gap for Pacific peoples remained largely unchanged. However, substantial ethnic inequities persist.

Further gains and closing of the gap are likely to depend on strengthening primary prevention, particularly continued reductions in smoking and improved management of cardiovascular disease risk factors. Screening and early detection programmes, including the potential implementation of lung cancer screening, offer additional opportunity to improve survival, particularly if delivered in ways that reach populations at highest risk. Prioritising interventions where the potential for health gain is greatest, and ensuring equitable access across prevention, screening and treatment, will be critical to reducing mortality and narrowing remaining life expectancy gaps, alongside continued attention to the structural determinants that shape exposure to risk and access to care.