Reversing East-West mortality difference among German women, and the role of smoking

Background The German East-West mortality difference narrowed rapidly after the 1990 unification, particularly for women. We analyse recent trends for women aged 50-89 years and document for the first time lower mortality in the East. We study how smoking contributes to this cross-over. Methods We analyse mortality by cause for women aged 50-89 over the years 1992-2009 for the East and West Germany, excluding Berlin. We compare the East-West mortality rate ratio (MRR) for total mortality and after removing smoking-attributable mortality using the indirect Preston-Glei-Wilmoth method. Results In the early 1990s mortality was higher in the East. By 2000 mortality for ages 50-64 had declined below that of the West and remained lower thereafter. For example, from 1992-94 to 2005-09 the MRR for ages 55-59 declined from 1.27 to 0.87. Smoking explains a third of the MRR change for ages 50-64, and when smoking-attributable deaths are removed the mortality cross-over vanishes. For example, non-smoking-attributable MRR for ages 55-59 is 1.03 in 2005-09. For ages 65-89 smoking matters less, and mortality remains higher in the East. Conclusions We show for the first time that mortality for middle-aged women is lower in the former East Germany than in the West. Prior studies have documented convergence and suggested improving living standards and medical care as mechanisms. We show that much of the convergence, and the cross-over, are attributable to smoking. The seeds for the female East-West mortality cross-over were planted before the unification, when the women now aged 50-64 adopted their smoking behaviours.