Smoking is among the leading determinants of international differences in mortality, the gender gap in mortality and mortality differences between socioeconomic groups. However, only a few studies have explored the impact of smoking on regional differences in mortality.
To begin to close this research gap, the authors Pavel Grigoriev and Sebastian Klüsener (German Federal Institute for Population Research) and Alyson van Raalte (Max Planck Institute for Demographic Research) examine the effect of smoking on German regional differences in mortality. Germany presents an interesting case study because of its substantial regional variation in both smoking and mortality patterns and its surge of women smoking prior to reunification. The cross-sectional study assesses the contribution of smoking – more precisely the ensuing lung cancer – to regional mortality differences in Germany over the last four decades. For this, they divided the cause-specific data, stratified by sex and age, from 1980 to 2019 into five regions: East, North, South, West-I and West-II. This division captures the long-standing macro-regional differences in Germany’s social and economic development as well as in mortality.
As the rise in women smokers occurred much later than among men, we must take the differentiation by sex into account to understand the regional patterns at play. Most pressingly, the authors find that the recent decline in smoking among men is not happening among women. However, even though much more women smoke today in comparison to past trends, the numbers are much lower than for men.
Results indicate that in Western Germany, the intensity of the smoking epidemic among men had a determining effect on the level of the spread among women. In other words, when smoking became popular among men, women tended to follow the same behaviour. Smoking in Western Germany was also associated with women’s rights movements, whereas in the East women smoking was strongly discouraged. Women's smoking behaviour still reflects a historically determined east-west divide.
In addition to the east-west divide, the researchers note that a more substantial consideration for both sexes, is the tendency, for smoking prevalence to be higher in the north than in the south. This reflects known mortality differences and is observable when looking at the smoking-attributable fraction of people over 50 years who have died of lung cancer. For example, in 1995, 22% of deaths among men at ages 50 and above in the North were due to smoking, while only 17% in the South. Among women, 4% of deaths were associated with smoking in the north and 2% in the south. For men, both of these rates decreased by 6% by 2019, while for women they more than doubled.
The North–South divide in smoking histories and its effect on lung cancer mortality is the main determinant of current male regional mortality disparities in Germany, despite the number of smoking-attributable deaths declining overall. Among women, smoking has recently become a key parameter of regional differences and its relevance can be expected to further gain importance in the decades to come. It underlines clear insights that smoking initiation is mostly socially patterned, including the ways it is advertised and accepted within a society. Health policies aiming at reducing regional inequalities should therefore account for regional differences in past smoking behaviour.