Quantifying the contribution of smoking to regional mortality disparities in Germany: a cross-sectional study

Abstract

ObjectivesSubstantial regional variation in smoking behaviour in Germany has been well documented. However, little is known about how these regional differences in smoking affect regional mortality disparities. We aim to assess the contribution of smoking to regional mortality differentials in Germany over the last four decades.DesignA cross-sectional study using official cause-specific mortality data by German Federal State aggregated into five macro-regions: East, North, South, West-I and West-II.ParticipantsThe entire population of Germany stratified by sex, age and region during 1980–2019.Main outcome measuresSmoking-attributable fraction estimated using the Preston-Glei-Wilmoth method; life expectancy at birth before and after the elimination of smoking-attributable deaths.ResultsIn all macro-regions, the burden of past smoking has been declining among men but growing rapidly among women. The hypothetical removal of smoking-attributable deaths would eliminate roughly half of the contemporary advantage in life expectancy of the vanguard region South over the other macro-regions, apart from the East. In the latter, smoking only explains around a quarter (0.5 years) of the 2-year difference in male life expectancy compared with the South observed in 2019. Among women, eliminating smoking-attributable deaths would put the East in a more disadvantageous position compared with the South as well as the other macro-regions.ConclusionWhile regional differences in smoking histories explain large parts of the regional disparities in male mortality, they are playing an increasingly important role for female mortality trends and differentials. Health policies aiming at reducing regional inequalities should account for regional differences in past smoking behaviour.

An Innovative Visual Approach to Monitor Simultaneously Two Dimensions of Progress in Longevity: An Application to French and German Regions

“…This “Matthew Effect” [34], when national mortality decrease is paralleled by regional inequality increase, contrasts with the strong relationship we globally observe between nationwide mortality and absolute regional inequality. For women aged 35 to 64, this increase is mostly driven by regional differences in smoking behaviour [35]: mortality rates for these ages are stalling or increasing in some regions of central Germany. Finally, the decline in infant mortality between 1992 and 2019 was associated with different phases of convergence (1992–1998; 2007–2019) and divergence (1998–2007).…”

Area-based socioeconomic inequalities in cancer mortality in Germany – widening, narrowing or reversing inequalities between 2003 and 2019?

“…These differences still exist 30 years after the German reunification and are associated with socioeconomic inequalities between the two parts of the country. However, the results of the study also suggest that this regional divide may change to a north-south divide with lower cancer mortality in the south than in the north in the future [18][19][20] . German health insurance data offer the advantage of large case numbers, detailed diagnosis documentation and information on socioeconomic position and mortality of the insurance population at the individual level.…”

“…Due to data restrictions by law, the German death statistics and cancer registries do not contain any information on socioeconomic status, such as education, occupation or income. The few studies available are therefore based either on health insurance data 6,17 , which contain certain socioeconomic information about the insured individuals, or on regional comparisons using data of the German cause-of-death statistics [18][19][20] .…”

“…First studies for Germany indicate considerable regional and socioeconomic disparities in cancer mortality 6,[17][18][19][20] . Recent studies based on German health insurance data report increases in cancer-free life expectancy for total as well as for most of the most common site-specific cancers over time 6,17 .…”

The socioeconomic gap in life expectancy in Germany: a decomposition of age- and cause-specific mortality contributions, 2003–2021

“…lung, colon and rectal, pancreatic, stomach, breast, prostate) are the leading causes of death [9, 18, 19]. In terms of cancer mortality, regional analyses found clear east-west differences in smoking-related and preventable-cancer mortality, with higher levels of mortality in the eastern part of Germany [9, 20]. In addition, a north-south divide was reported with lower cancer mortality in the less deprived districts in southern Germany [18].…”