Deciphering trends in smoking-attributable cardiovascular mortality in Germany in the face of population ageing

Introduction
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 been decreasing in recent decades, population ageing leads to increasing numbers of deaths. To explore the contribution of smoking to cardiovascular mortality against the background of these different trends at a population level, this study sought to decipher trends in smoking-attributable cardiovascular mortality (SACVM).

Methods
Smoking and mortality statistics from 1992 to 2021 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 suggest that total absolute SACVM strongly declined over time, from about 71,900 cases in 1992 to about 41,000 cases in 2021, with a stronger drop in men than in women. 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 2021. Sex-specific relative SACVM however showed differing trends: a strong decrease in men and a slight increase in women. The forward projection of SACVM indicates a slight decline in men and a marked increase in women.

Conclusions
Results indicate a strong decline in SACVM over the past three decades, but which was partly compensated by opposing trends in population ageing. Comprehensive tobacco control polices and an intensification of smoking cessation programs are required to curb the smoking-associated public health burden.