French mortality in figures: causes of death

Exploring causes of mortality through a few key questions

Graphic: Mortality by cause of death in France from 1925 to 2021.
What were people most likely to die of a century ago? Is it true that cancer is now the leading cause of death?

Table: Mortality by sex and cause of death category, in number of deaths per 100,000 inhabitants.
Holding the population age structure constant, is cardiovascular disease mortality declining? Under which cause of death group was the COVID-19 pandemic classified?

Some initial concepts and clarifications

Cause of death statistics are based on information contained in the medical certificate of death completed by the physician certifying the death of an individual, in which they describe the chain of causes resulting in the death. INSERM then encodes all the information using the WHO’s International Classification of Diseases in order to determine the underlying cause of death. The underlying (or primary) cause of death is the cause considered to have initiated the process resulting in death. The fact that deaths are occurring at increasingly older ages among individuals suffering from multiple interrelated chronic conditions can make identifying the underlying cause of death more difficult.

Analysing mortality rates by cause provides a better understanding of changes in mortality, whether these are sudden shifts or long-term trends. Interactive graphic

Guide to this graphic

For every death that occurs in France, a doctor is required to complete a medical certificate of death, indicating the chain of medical causes contributing to the death. The certificate is then submitted to the civil registry office, which sends the administrative section to INSEE and the section on causes of death to INSERM, sealed to protect the confidentiality of the information. INSERM then encodes all the causes mentioned using the WHO’s International Classification of Diseases, in order to determine the underlying cause of death.

The underlying (or primary) cause of death is the cause that initiated the process resulting in death. Analysing mortality rates by cause provides a better understanding of changes in mortality, whether these are sudden shifts or long-term trends. Given that the level of mortality is influenced both by age-specific probabilities of death and by the age structure of the population—a structure that has changed considerably over the 20th century in France, with significant ageing of the population—the rates presented here are age-standardized, i.e. adjusted for differences in the population’s age structure, in order to facilitate comparison over time.

Long-term decline in communicable disease mortality

The considerable progress in life expectancy at birth achieved over the 20th century began with the decline in mortality due to communicable diseases, which occurred particularly rapidly during the earlier half of the century. Thanks initially to advances in hygiene and nutrition from the late 18th century onwards in France, the decline was subsequently driven primarily by the efficacy of vaccination campaigns and by the discovery of antibiotics in the 1930s, followed by their large-scale use in the 1940s and 1950s. The age-standardized communicable disease mortality rate, which reached more than 700 deaths per 100,000 inhabitants in the mid-1920s, fell by half to 350 following World War II, again to 140 by 1958, and had dropped to fewer than 50 by around 2000. This decline, which has continued to the present day, was interrupted by war and by successive but increasingly less lethal epidemics as vaccination became more widespread (particularly in terms of flu and, more recently, COVID-19) and in line with advances in medicine (including in the fight against HIV/AIDS).

Chronic disease control

Since the 1930s, communicable diseases, previously the leading cause of death, made way for cardiovascular diseases, which remained at the top of the rankings until the late 1980s. Cardiovascular disease control was initiated during the 1960s and is almost entirely responsible for the increase in life expectancy at birth observed during the 1970s and 1980s. This progress was driven by multiple shifts: behavioural changes (with the discovery of the links between smoking and mortality and the ensuing anti-smoking campaigns and increasingly strict legislation); progress in preventive medicine (the invention of beta-blockers and statins in particular) and surgery (the first open-heart surgery took place in 1976); and changes in the organization of healthcare (with the creation of specific coronary care units).

Consequently, the age-standardized cardiovascular disease mortality rate fell to around one tenth of its previous level between 1940 and 2020, from 730 deaths per 100,000 to just 85. In 1991, cancer topped the rankings of the leading causes of death. The age-standardized cancer mortality rate had peaked a few years earlier (at 225 per 100,000 in the early 1980s). Since then, it has been declining as a result of reduced alcohol and tobacco consumption. However, the effects of smoking on the age-standardized cancer mortality rate are only observed about thirty years later, whereas they are immediate in relation to cardiovascular disease mortality.

The decrease in mortality due to malignant tumours is also explained by the efficacy of screening and prevention campaigns for the most lethal cancers (cervical and breast cancer in women, prostate cancer in men, and bowel cancer in both sexes) and by treatment advances (particularly for leukaemia and lung cancer) over the past two or three decades. However, this decline has been much slower than for cardiovascular disease due to the lesser efficacy of treatments and the deferred effects of changing smoking behaviours in women, among whom the proportion of smokers fell much later than among men.