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Here we recruited 500,810 adults aged \u226535\u2009years from Chennai city during 1998\u20132001 in South India and followed to 2020 for verbal-autopsy-assessed cause-specific mortality. Among those initially without chronic disease, multivariable-adjusted Cox regression (censored at age 70\u2009years) related initial characteristics to mortality rates. Even among non-smoking non-drinkers, those with no schooling had almost three times the mortality rate ratio (RR) of those with &gt;11\u2009years education (men, RR of 2.76, 95% confidence interval (CI) 2.58\u20132.95; women, RR of 2.93, 95% CI 2.69\u20133.19), with substantial mortality excesses from each major disease category. These social inequalities were further exacerbated by much higher smoking and drinking prevalences among less educated men. Adjusted for education, male smoking (versus not, RR of 1.26, 95% CI 1.22\u20131.29) and drinking (versus not, RR of 1.52, 95% CI 1.48\u20131.56) were independently associated with risk and together almost doubled male mortality (both versus neither, RR of 1.89, 95% CI 1.84\u20131.94). Few women (&lt;0.1%) smoked or drank.<\/jats:p>","DOI":"10.1038\/s44360-026-00148-4","type":"journal-article","created":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T09:02:24Z","timestamp":1781859744000},"page":"1082-1091","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Combined impact of smoking, alcohol and social inequalities on premature mortality in urban India"],"prefix":"10.1038","volume":"1","author":[{"ORCID":"https:\/\/orcid.org\/0009-0005-2438-3012","authenticated-orcid":false,"given":"Vendhan","family":"Gajalakshmi","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9181-6886","authenticated-orcid":false,"given":"Fiona","family":"Bragg","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0139-2934","authenticated-orcid":false,"given":"Ben","family":"Lacey","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vendhan","family":"Kanimozhi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9403-6906","authenticated-orcid":false,"given":"Manigandan","family":"Chandrasekaran","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ramu Ashok","family":"Kumar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul","family":"Sherliker","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8219-5339","authenticated-orcid":false,"given":"Richard","family":"Peto","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4496-4771","authenticated-orcid":false,"given":"Sarah","family":"Lewington","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,6,19]]},"reference":[{"key":"148_CR1","doi-asserted-by":"publisher","first-page":"15","DOI":"10.1016\/j.ypmed.2018.05.003","volume":"113","author":"D Petrovic","year":"2018","unstructured":"Petrovic, D. et al. The contribution of health behaviors to socioeconomic inequalities in health: a systematic review. Prev. Med. 113, 15\u201331 (2018).","journal-title":"Prev. Med."},{"key":"148_CR2","doi-asserted-by":"publisher","first-page":"277","DOI":"10.1016\/S2214-109X(17)30058-X","volume":"5","author":"L Allen","year":"2017","unstructured":"Allen, L. et al. Socioeconomic status and non-communicable disease behavioural risk factors in low-income and lower-middle-income countries: a systematic review. Lancet Glob. Health 5, 277\u2013289 (2017).","journal-title":"Lancet Glob. Health"},{"key":"148_CR3","doi-asserted-by":"publisher","first-page":"180553","DOI":"10.5888\/pcd16.180553","volume":"16","author":"BE Garrett","year":"2019","unstructured":"Garrett, B. E., Martell, B. N., Caraballo, R. S. & King, B. A. Socioeconomic differences in cigarette smoking among sociodemographic groups. Prev. Chronic Dis. 16, 180553 (2019).","journal-title":"Prev. 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HDRUK2023.0028) funded by the MRC, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Department of Health and Social Care (England), Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Health and Social Care Research and Development Division (Welsh Government), Public Health Agency (Northern Ireland), BHF and Cancer Research UK. The Clinical Trial Service Unit and the Epidemiological Studies Unit at the University of Oxford receives research grants from industry that are governed by University of Oxford contracts, which protects the independence of the Clinical Trial Service Unit and the Epidemiological Studies Unit. The other authors declare no competing interests.","order":1,"name":"Ethics","label":"Competing interests","group":{"name":"EthicsHeading","label":"Ethics"}}]}}