gms | German Medical Science

Introduction: Tobacco smoking persists as a significant public health issue in Germany, particularly among disadvantaged socioeconomic groups and despite strengthened reduction efforts following Germany’s ratification of the World Health Organization’s Framework Convention on Tobacco Control in 2004 [1], [2], [3]. However, research on smoking behavior across socioeconomic strata in Germany is scarce. This study aimed to analyze smoking behavior trends in Germany over 23 years, using high-quality smoking data, and to investigate possible health equity implications of tobacco control.

Methods: We conducted a cross-sectional descriptive analysis examining trends in smoking behavior across equivalized income and education levels in Germany from 1998 to 2020. We extracted 13 waves of biannual cross-sectional data from the German Socioeconomic Panel of adults aged 25-64. Smoking prevalence was assessed via self-reported smoking status (binary), and intensity was assessed as average consumed tobacco products per smoker per day (CTP). Outcomes were stratified by education using the Comparative Analysis of Social Mobility in Industrial Nations classification and quintiles of net equivalized income. We additionally analyzed smoking inequalities between 1998 and 2020 by means of comparing prevalence differences and ratios across socioeconomic strata. Population representativeness was achieved using cross-sectional survey weights.

Results: We find that declining trends in overall smoking prevalence were mainly driven by highly educated individuals (1998: 24.31% with 95% CI: 21.74-26.89; 2020: 14.06% with 95% CI: 12.40-15.71) and those with high incomes (1998: 30.48% with 95% CI: 27.84-33.12; 2020: 16.32% with 95% CI: 14.22-18.42). For individuals in the lowest educational group, smoking prevalence increased from 39.64% (95% CI: 36.75-42.52) in 1998 to 43.61% (95% CI: 39.85-47.37) in 2020. Similarly, those in the lowest income quintile had the smallest decrease across income groups. Similar inverse relationships were found between socioeconomic characteristics and smoking intensity. For people with an academic degree, smoking intensity declined from 15.27 CTP (95% CI: 14.06-16.47) in 1998 to 10.13 CTP (95% CI: 9.29-10.96) in 2020, which was the lowest value across socioeconomic strata. People with higher and intermediate education exhibited a moderate overall reduction in smoking intensity, and individuals with no graduation or basic education recorded the highest smoking intensity, averaging 18.78 (95% CI: 17.81-19.74) in 1998 and 16.12 CTP (95% CI: 15.10-17.14) in 2020. The comparisons of socioeconomic inequality measures suggest a widening of the gap for both the highest versus the lowest income and education groups between 1998 and 2020 (e.g., prevalence difference for income in 1998: 11.86 and 2020: 23.07 and for education in 1998: 15.32 and 2020: 29.55).

Conclusion: Our findings suggest that socioeconomic inequalities in smoking behavior have increased in Germany between 1998 and 2020, a period of increased tobacco regulations. Like others, we show that tobacco regulations do not necessarily reduce health inequalities [4]. To combat the adverse health effects of smoking and resulting health inequalities more effectively, health equity considerations need to be assessed and integrated more thoroughly into smoking policies in Germany [5].

The authors declare that they have no competing interests.

The authors declare that an ethics committee vote is not required.