Evolution of smoking-attributable cardiovascular mortality in Germany 1992-2020

Abstract

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Marga and Walter Boll Foundation, Kerpen, Germany. Background Despite comparatively weak tobacco control, smoking has steadily declined in Germany over the last 30 years. At the same time, while cardiovascular mortality rates have generally been decreasing in recent decades, population ageing leads to increasing numbers of deaths. Purpose To explore the impact of smoking prevalence on cardiovascular mortality against the background of these different trends at a population level, this study sought to quantify trends in smoking-attributable cardiovascular mortality (SACVM) in Germany over the past three decades. Methods Smoking and mortality statistics from 1992 to 2020 were obtained from the German Statistical Office, from which absolute and relative SACVM was calculated separately for each cardiovascular cause of death causally associated with smoking. The impact of population ageing was explored by comparing crude and age-standardized SACVM, respectively. To estimate the impact of population ageing on future SACVM, a forward projection until 2035 was modelled assuming constant mortality rates and a continuation of smoking trends. Results Results show that total absolute SACVM strongly declined over time, from about 71,900 cases in 1992 to about 42,000 cases in 2020, with a stronger drop in men (from about 51,200 to 26,400 cases) than in women (from about 20,700 to 15,600 cases). Somewhat stronger declines were seen for age-adjusted SACVM, with differences between crude and age-standardized SACVM being somewhat more distinct in men. Relative SACVM decreased overall, from 17.3% in 1992 to 14.6% in 2020. Sex-specific relative SACVM however showed differing trends: a strong decrease in men (from 29.3% to 18.8%) and a slight increase in women (8.6% to 10.6%). The forward projection of SACVM indicates a slight decline among men and a marked increase in women. Conclusions Results indicate that SACVM has strongly declined over the past three decades, even though being partly compensated by opposing trends in population ageing. The marked decrease in absolute SACVM seems to be mostly due to the general drop in cardiovascular mortality rates, and only partly due to declining smoking rates, particularly in women, where relative SACVM has even slightly increased. Over the next 15 years, population ageing and the increasing trend in relative SACVM among women might halt the recent declining trend in absolute SACVM. Hence, there is tremendous potential to curb the smoking-associated public health burden by implementing a comprehensive set of evidence-based tobacco control polices. Additionally, given still significant smoking rates in middle and old age, smoking cessation programs should be intensified.