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Background The US rural disadvantage in life expectancy (LE) relative to urban areas has grown over time. We measured the contribution of cardiovascular disease (CVD), drug-overdose deaths (DODs) and other major causes of death to LE trends in rural and urban counties and the rural–urban LE gap. Methods Counterfactual life tables and cause-of-death decompositions were constructed using data on all US deaths in 1999–2019 (N = 51 998 560) from the Centers for Disease Control and Prevention. Results During 1999–2009, rural and urban counties experienced robust LE gains, but urban LE increased by 1.19 years more in women and 0.86 years more in men compared with rural LE. During 2010–2019, rural counties experienced absolute declines in LE (women −0.20, men −0.30 years), whereas urban counties experienced modest increases (women 0.55, men 0.29 years). Counterfactual analysis showed that slowed CVD-mortality declines, particularly in ages 65+ years, were the main reason why rural LE stopped increasing after 2010. However, slow progress in CVD-mortality influenced LE trends more in urban areas. If CVD-mortality had continued to decline at its pre-2010 pace, the rural–urban LE gap would have grown even more post 2010. DODs and other causes of death also contributed to the LE trends and differences in each period, but their impact in comparison to that of CVD was relatively small. Conclusions Rural disadvantage in LE continues to grow, but at a slower pace than pre 2010. This slowdown is more attributable to adverse trends in CVD and DOD mortality in urban areas than improvements in rural areas.

The growing rural–urban divide in US life expectancy: contribution of cardiovascular disease and other major causes of death