Socioeconomic inequalities in smoking prevalence and intensity in Germany: A repeated cross-sectional analysis from 1998 to 2024
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Background
Smoking inequalities by socioeconomic status have widened consistently in Germany, but sex-specific trends after 2013 and inequalities in daily cigarette consumption among smokers (intensity) are unknown. We analyzed trends in absolute and relative socioeconomic inequalities in smoking prevalence and intensity among German adults across three decades.
Methods
We used 14 waves (1998-2024) of population-representative cross-sectional data from the German Socio-Economic Panel to estimate sex-specific trends in smoking prevalence and intensity in adults aged 25-64. Inequalities were quantified across strata of education, occupation, and equivalized household income using the absolute and relative concentration index with 95% bootstrap confidence intervals.
Results
Overall smoking prevalence declined from 35.05% (CI: [33.90%, 36.20%] in 1998 to 22.19% (CI: [21.15%, 23.24%]) in 2024, and mean intensity from 17.49 (CI: [17.09,17.90]) to 13.33 (CI: [12.88, 13.79]) cigarettes/day. Over this period sex-differences in both outcomes narrowed almost completely. Absolute and relative inequalities in smoking prevalence widened across all SES dimensions, particularly for education and occupation. By 2024, inequalities were larger among women than men driven by a stagnating or rising smoking prevalence among low-SES women at least until 2018 alongside continued declines in higher-SES women and for men. Inequalities in smoking intensity, particularly related to income, were generally smaller than those in prevalence.
Conclusion
Socioeconomic smoking inequalities in Germany widened from 1998 to 2024 primarily driven by reductions among higher-SES groups and increases in low-SES women. However, recent reductions in low-SES women may indicate a new phase in the smoking epidemic. Health equity considerations should be integrated into a targeted German tobacco control strategy.
Key messages
What is already known on this topic:
– Socioeconomic inequalities in smoking, particularly according to education, have been increasing in Germany since the 1990s
– Among men this increase was driven by reductions in smoking for those with a higher socioeconomic status, while among women, smoking prevalence has additionally increased for those with a lower socioeconomic status
– It is unknown how inequalities in smoking prevalence and intensity according to education, occupation, and income have developed in Germany over the last 10 to 15 years
What this study adds:
– Socioeconomic inequalities in smoking prevalence in Germany have continuously widened over almost three decades for both men and women but very recent trends may indicate a decline in inequalities in women due to a decreasing prevalence in low educated women
– Socioeconomic inequalities in smoking intensity have also increased over time and are most relevant across strata of education and occupation
– For smoking prevalence inequalities are now larger and have increased faster among women compared to men but inequalities in smoking intensity are much larger among men
How this study might affect research, practice or policy:
– Germany may be about to enter a new phase of the smoking epidemic where the prevalence of smoking among the most disadvantaged groups is starting to decline
– Smoking seems to be an important driver of health inequalities in Germany, particularly among women
– As socioeconomic inequalities in smoking are substantial, there is a need for tobacco regulation that effectively reduces smoking overall and among disadvantaged groups
