An innovative visual approach to the simultaneous study of two dimensions of progress in longevity: an application to French and German regions.

BACKGROUND: Both enhancing life expectancy and decreasing inequalities in lifespan between social groups are significant goals for public policy. To date, however, methodological tools to study progress in both dimensions simultaneously have been lacking. There is also a consensus that absolute and relative inequalities in lifespan must be studied together. METHODS: We introduce a novel graphical representation that combines national mortality rates with both absolute and relative measures of social inequality in mortality. To illustrate our approach, we analyze French and German data stratified by place of residence. RESULTS: For all-age mortality, in France we find a steady pace of decline in both mortality and in regional inequalities in mortality over recent decades. In Germany, substantial progress was made in the 1990s, mostly driven by convergence between eastern and western Germany, followed by a period of slower progress. Age-specific analyses for Germany reveal a worrying divergence in regional trends at ages 35-74 in recent years, which is particularly pronounced among women. CONCLUSION: Our novel visual approach offers a way to simultaneously examine two dimensions of progress in longevity, and facilitates meaningful comparisons between populations, even when their current mortality rates differ. The applied methods can be easily reproduced in any country for which long-term mortality series stratified by region, or any relevant socioeconomic characteristic, are available. It is useful for both scientific analysis and policy advice.

Method for redistributing ill-defined causes of death.

Analysis of causes of death is crucial for monitoring an epidemiological situation and for developing adequate policy responses. However, the comparability of cause-specific mortality data depends on the proportion of ill-defined deaths. To eliminate the bias resulting from the varying proportions of such causes over time and between populations, deaths from ill-defined causes need to be reassigned to other categories. We provide thorough documentation of and tools for the practical implementation of a regression-based method for redistributing ill-defined causes of death, as first proposed by Sully Ledermann in the 1950s. The method relies on subnational cause-specific mortality data to estimate unbiased death rates at both national and subnational levels. We refine Ledermann's method by elaborating on its mathematical properties, making additional adjustments, and evaluating the performance of the approach through simulations. To illustrate the practical application of the method, we rely on French subnational cause-of-death data and provide the R code for performing all calculations.

[Regional differences and trends in healthy life expectancy in Germany]. / Regionale Unterschiede und Trends in gesunder Lebenserwartung in Deutschland.

BACKGROUND: Against the background of increasing life expectancy, the question arises in which state of health the additional years of life are spent. The aim of this study is to assess for the first time regional differences in healthy life expectancy for Germany. METHODS: The concept of healthy life expectancy allows for the combination of regional differences in health status and mortality in a single measure. This article uses the concept of partial healthy life expectancy. We use official data on deaths and population numbers to calculate abridged life tables. Data from the Socio-Economic Panel (SOEP) are used to determine the age- and sex-specific prevalences of health status. Regional differences are analyzed from 2002 to 2019 by dividing Germany into four regions (North, South, East, West). RESULTS: The regional differences in healthy life expectancy in Germany are greater than differences in life expectancy, and trends in healthy life expectancy partly differ from the corresponding trends in mortality. These differences over time also vary according to age: while healthy life expectancy has tended to stagnate and, in some cases, decline among the population aged between 20 and 64, the number and proportion of years in good health has increased among older adults up to the age of 79. CONCLUSION: There are striking regional differences and trends in the distribution of expected years in good health in Germany. The timely identification of regionally divergent developments could facilitate the implementation of targeted health-promoting measures.

[Mortality trends in Germany in an international context]. / Sterblichkeitsentwicklung in Deutschland im internationalen Kontext.

BACKGROUND AND AIM: Due to its strong economy and a well-developed healthcare system, Germany is well positioned to achieve above-average reductions in mortality. Nevertheless, in terms of life expectancy, Germany is increasingly falling behind Western Europe. We compare mortality trends in Germany with other Western European countries, covering the period from 1960 to 2019. The focus is on long-term trends in Germany's ranking in international mortality trends. In addition, we conduct a detailed mortality analysis by age. METHODS: Our analysis is mostly based on mortality data from the Human Mortality Database (HMD). Cause-specific mortality data originate from the database of the World Health Organization (WHO). For the international comparison of mortality trends, we use conventional mortality indicators (age-standardized mortality rate, period life expectancy). RESULTS: Compared to other Western European countries, Germany has higher mortality in the middle and older age groups. Germany's life expectancy gap compared to Western Europe has grown during the past 20 years. In 2000, Germany was 0.73 years behind for men and 0.74 years behind for women. By 2019, these figures had risen to 1.43 and 1.34 years, respectively. This is mainly due to mortality from non-communicable diseases. CONCLUSION: For Germany to catch up with other Western European countries, a stronger focus on further reducing mortality at ages 50+ is crucial. This also requires further research to understand the factors behind Germany's disadvantageous position.

The underwhelming German life expectancy.

This article contributes to the discussion on the determinants of diverging life expectancy in high-income countries, with a focus on Germany. To date, much of this discourse has centered around the social determinants of health, issues of healthcare equity, poverty and income inequality, and new epidemics of opioids and violence. Yet despite doing well on all of these metrics and having numerous advantages such as comparatively strong economic performance, generous social security, and an equitable and well-resourced health care system, Germany has been a long-time life expectancy laggard among the high-income countries. Using aggregated population-level mortality data for Germany and selected six high-income countries (Switzerland, France, Japan, Spain, the United Kingdom, and the United States) from the Human Mortality Database and WHO Mortality Database, we find that the German longevity shortfall is mainly explained by a longstanding disadvantage in survival among older adults and adults nearing statutory retirement age, which mainly stems from sustained excess cardiovascular disease mortality, even when compared to other laggard countries such as the US and the UK. Patchy contextual data suggests that the unfavorable pattern of cardiovascular mortality may be driven by underperforming primary care and disease prevention. More systematic and representative data on risk factors are needed to strengthen the evidence base on the determinants of the controversial and long-standing health gap between more successful countries and Germany. The German example calls for broader narratives of population health that embed the variety of epidemiological challenges populations face around the globe.

Sex differences in cause-specific mortality: regional trends in seven European countries, 1996-2019.

BACKGROUND: Male excess mortality is mostly related to non-biological factors, and is thus of high social- and health-policy concern. Previous research has mainly focused on national patterns, while subnational disparities have been less in the focus. This study takes a spatial perspective on subnational patterns, covering seven European countries at the crossroad between Eastern and Western Europe. METHODS: We analyze a newly gathered spatially detailed data resource comprising 228 regions with well-established demographic methods to assess the contribution of specific causes of death to the evolution of sex mortality differentials (SMDs) since the mid-1990s. RESULTS: Our results show that declines in SMDs were mostly driven by a reduction of male excess mortality from cardiovascular diseases and neoplasms (about 50-60% and 20-30%, respectively). In Western Europe, trends in deaths from neoplasms contributed more to the reduction of SMDs, while among regions located in Eastern-Central Europe narrowing SMDs were mostly driven by changes in cardiovascular disease-related deaths. Moreover, men show up to three times higher mortality levels from external causes as compared to women in several analyzed regions. But in absolute terms, external deaths play only a minor role in explaining SMDs due to their small contribution to overall mortality. CONCLUSIONS: We conclude that examining the regional development of SMDs is useful for introducing targeted social and health policies in order to reduce and prevent mortality inequalities between women and men.

[30 years of German unification: achievements and remaining differences in mortality trends by age and cause of death]. / 30 Jahre Deutsche Einheit: Errungenschaften und verbliebene Unterschiede in der Mortalitätsentwicklung nach Alter und Todesursachen.

BACKGROUND: During the German division, two culturally very similar populations were exposed to very disparate socioeconomic conditions, which converged again after 1989. The impact of healthcare and life circumstances on mortality differences can better be estimated when cultural explanations are widely neglectable. OBJECTIVES: For the first time, we analyse harmonised cause-of-death data explicitly by age. Hereby, we can show which ages or birth cohorts were particularly affected by German division and reunification in their mortality and to which causes of death this is attributable. MATERIALS AND METHODS: We harmonised the German cause-of-death statistics by applying an internationally standardised harmonisation process to account for differences and breaks in cause-of-death coding practices. We analysed the data using decomposition methods. RESULTS: During the 1980s, east-west disparities were increasing as progress in the reduction of cardiovascular mortality was much stronger in West Germany, notably at older ages. After 1989, East Germany was able to catch up to the west in many areas. This is especially true for elderly persons and women, while east-west disparities are still visible today, particularly among male adult cohorts (1950-1970) strongly affected by the East German transition crisis. CONCLUSIONS: The lower life expectancy of the East German population in the late 1980s was primarily caused by a slower pace of the cardiovascular revolution. The remaining present-day disparities are rather an aftermath of the East German transition crisis than direct aftereffects of the division.

The German East-West Mortality Difference: Two Crossovers Driven by Smoking.

Before the fall of the Berlin Wall, mortality was considerably higher in the former East Germany than in West Germany. The gap narrowed rapidly after German reunification. The convergence was particularly strong for women, to the point that Eastern women aged 50-69 now have lower mortality despite lower incomes and worse overall living conditions. Prior research has shown that lower smoking rates among East German female cohorts born in the 1940s and 1950s were a major contributor to this crossover. However, after 1990, smoking behavior changed dramatically, with higher smoking intensity observed among women in the eastern part of Germany. We forecast the impact of this changing smoking behavior on East-West mortality differences and find that the higher smoking rates among younger East German cohorts will reverse their contemporary mortality advantage. Mortality forecasting methods that do not account for smoking would, perhaps misleadingly, forecast a growing mortality advantage for East German women. Experience from other countries shows that smoking can be effectively reduced by strict anti-smoking policies. Instead, East Germany is becoming an example warning of the consequences of weakening anti-smoking policies and changing behavioral norms.

Disparities in length of life across developed countries: measuring and decomposing changes over time within and between country groups.

BACKGROUND: Over the past half century the global tendency for improvements in longevity has been uneven across countries. This has resulted in widening of inter-country disparities in life expectancy. Moreover, the pattern of divergence appears to be driven in part by processes at the level of country groupings defined in geopolitical terms. A systematic quantitative analysis of this phenomenon has not been possible using demographic decomposition approaches as these have not been suitably adapted for this purpose. In this paper we present an elaboration of conventional decomposition techniques to provide a toolkit for analysis of the inter-country variance, and illustrate its use by analyzing trends in life expectancy in developed countries over a 40-year period. METHODS: We analyze trends in the population-weighted variance of life expectancy at birth across 36 developed countries and three country groups over the period 1970-2010. We have modified existing decomposition approaches using the stepwise replacement algorithm to compute age components of changes in the total variance as well as variance between and within groups of Established Market Economies (EME), Central and Eastern Europe (CEE), and the Former Soviet Union (FSU). The method is generally applicable to the decomposition of temporal changes in any aggregate index based on a set of populations. RESULTS: The divergence in life expectancy between developed countries has generally increased over the study period. This tendency dominated from the beginning of 1970s to the early 2000s, and reversed only after 2005. From 1970 to 2010, the total standard deviation of life expectancy increased from 2.0 to 5.6 years among men and from 1.0 to 3.6 years among women. This was determined by the between-group effects due to polarization between the EME and the FSU. The latter contrast was largely fueled by the long-term health crisis in Russia. With respect to age, the increase in the overall divergence was attributable to between-country differences in mortality changes at ages 15-64 years compared to those aged 65 and older. The within-group variance increased, especially among women. This change was mostly produced by growing mortality differences at ages 65 and older. CONCLUSIONS: From the early 1970s to the mid-2000s, the strong divergence in life expectancy across developed countries was largely determined by the between-group variance and mortality polarization linked to the East-West geopolitical division.

Spatial variation of male alcohol-related mortality in Belarus and Lithuania.

BACKGROUND: Numerous studies have addressed the problem of hazardous alcohol consumption, alcohol-related causes of death and their relationship to persisting excess male mortality in the countries of the former USSR. Yet relatively little is known about the geographical patterns of alcohol-related mortality within these countries and the cross-border continuities of such patterns. This study aims at identifying the spatial distribution and the cross-border patterns of adult male mortality from alcohol poisonings and liver cirrhosis in Belarus and Lithuania. METHODS: We use cause-specific mortality data for 2003-2007. We employ spatial econometric techniques to detect 'hot spots' of alcohol-related mortality across the combined territory of the two countries. RESULTS: Specific patterns associated with extremely high rates of mortality from alcohol poisoning can be observed in Belarus, particularly in the areas bordering Russia and Lithuania. Meanwhile, patterns of alcohol-induced liver disease dominate in Lithuania, and continue across the border from eastern Lithuania into north-western Belarus. CONCLUSIONS: The districts located along the Belarusian-Lithuanian border appear to be especially problematic, as they suffer from an enormous burden of alcohol consumption. The situation is particularly severe on the Belarusian side, where there are extremely high levels of mortality from both alcohol poisoning and liver cirrhosis. These areas should be considered primary targets for antialcohol policies.

Spatial Variation in Excess Mortality Across Europe: A Cross-Sectional Study of 561 Regions in 21 Countries.

OBJECTIVE: To measure the burden of the COVID-19 pandemic in 2020 at the subnational level by estimating excess mortality, defined as the increase in all-cause mortality relative to an expected baseline mortality level. METHODS: Statistical and demographic analyses of regional all-cause mortality data provided by the vital statistics systems of 21 European countries for 561 regions in Central and Western Europe. Life expectancy losses at ages 0 and 60 for males and females were estimated. RESULTS: We found evidence of a loss in life expectancy in 391 regions, whilst only three regions exhibit notable gains in life expectancy in 2020. For 12 regions, losses of life expectancy amounted to more than 2 years and three regions showed losses greater than 3 years. We highlight geographical clusters of high mortality in Northern Italy, Spain and Poland, whilst clusters of low mortality were found in Western France, Germany/Denmark and Norway/Sweden. CONCLUSIONS: Regional differences of loss of life expectancy are impressive, ranging from a loss of more than 4 years to a gain of 8 months. These findings provide a strong rationale for regional analysis, as national estimates hide significant regional disparities.

Spatial disparities in the mortality burden of the covid-19 pandemic across 569 European regions (2020-2021).

Since its emergence in December 2019, the COVID-19 pandemic has resulted in a significant increase in deaths worldwide. This article presents a detailed analysis of the mortality burden of the COVID-19 pandemic across 569 regions in 25 European countries. We produce age and sex-specific excess mortality and present our results using Age-Standardised Years of Life Lost in 2020 and 2021, as well as the cumulative impact over the two pandemic years. Employing a forecasting approach based on CP-splines that considers regional diversity and provides confidence intervals, we find notable losses in 362 regions in 2020 (440 regions in 2021). Conversely, only seven regions experienced gains in 2020 (four regions in 2021). We also estimate that eight regions suffered losses exceeding 20 years of life per 1000 population in 2020, whereas this number increased to 75 regions in 2021. The contiguity of the regions investigated in our study also reveals the changing geographical patterns of the pandemic. While the highest excess mortality values were concentrated in the early COVID-19 outbreak areas during the initial pandemic year, a clear East-West gradient appeared in 2021, with regions of Slovakia, Hungary, and Latvia experiencing the highest losses. This research underscores the importance of regional analyses for a nuanced comprehension of the pandemic's impact.

Age-specific and cause-specific mortality contributions to the socioeconomic gap in life expectancy in Germany, 2003-21: an ecological study.

BACKGROUND: Earlier death among people in socioeconomically deprived circumstances has been found internationally and for various causes of death, resulting in a considerable life-expectancy gap between socioeconomic groups. We examined how age-specific and cause-specific mortality contributions to the socioeconomic gap in life expectancy have changed at the area level in Germany over time. METHODS: In this ecological study, official German population and cause-of-death statistics provided by the Federal Statistical Office of Germany for the period Jan 1, 2003, to Dec 31, 2021, were linked to district-level data of the German Index of Socioeconomic Deprivation. Life-table and decomposition methods were applied to calculate life expectancy by area-level deprivation quintile and decompose the life-expectancy gap between the most and least deprived quintiles into age-specific and cause-specific mortality contributions. FINDINGS: Over the study period, population numbers varied between 80 million and 83 million people per year, with the number of deaths ranging from 818 000 to 1 024 000, covering the entire German population. Between Jan 1, 2003, and Dec 31, 2019, the gap in life expectancy between the most and least deprived quintiles of districts increased by 0·7 years among females (from 1·1 to 1·8 years) and by 0·1 years among males (from 3·0 to 3·1 years). Thereafter, during the COVID-19 pandemic, the gap increased more rapidly to 2·2 years in females and 3·5 years in males in 2021. Between 2003 and 2021, the causes of death that contributed the most to the life-expectancy gap were cardiovascular diseases and cancer, with declining contributions of cardiovascular disease deaths among those aged 70 years and older and increasing contributions of cancer deaths among those aged 40-74 years over this period. COVID-19 mortality among individuals aged 45 years and older was the strongest contributor to the increase in life-expectancy gap after 2019. INTERPRETATION: To reduce the socioeconomic gap in life expectancy, effective efforts are needed to prevent early deaths from cardiovascular disease and cancer in socioeconomically deprived populations, with cancer prevention and control becoming an increasingly important field of action in this respect. FUNDING: German Cancer Aid and European Research Council.

Trends, patterns, and determinants of regional mortality in Belarus, 1990-2007.

We report analyses of regional trends in overall and cause-specific mortality in Belarus for the period 1990-2007. We explore the respective spatial patterns and attempt to determine the factors responsible for the regional mortality variation. The results show that inter-regional mortality differentials tend to rise, mainly because of the growing advantage of the capital over other regions. The increasing variation is associated with diverging trends in mortality from external causes of death. Mortality tends to be higher in the eastern part of the country. Regional data show that changes in mortality are largely explained by alcohol and socio-economic conditions, as measured by unemployment and poverty rates. Cardiovascular and external-cause mortality are strongly associated with alcohol and unemployment, while poverty is an important predictor of suicide and homicide mortality. Clusters of elevated mortality from certain cancers located in the contaminated zone point to the possible impact of the Chernobyl accident.

Evaluating Spatial, Cause-Specific and Seasonal Effects of Excess Mortality Associated with the COVID-19 Pandemic: The Case of Germany, 2020.

BACKGROUND: Evaluating mortality effects of the COVID-19 pandemic using all-cause mortality data for national populations is inevitably associated with the risk of masking important subnational differentials and hampering targeted health policies. This study aims at assessing simultaneously cause-specific, spatial and seasonal mortality effects attributable to the pandemic in Germany in 2020. METHODS: Our analyses rely on official cause-of-death statistics consisting of 5.65 million individual death records reported for the German population during 2015-2020. We conduct differential mortality analyses by age, sex, cause, month and district (N = 400), using decomposition and standardisation methods, comparing each strata of the mortality level observed in 2020 with its expected value, as well as spatial regression to explore the association of excess mortality with pre-pandemic indicators. RESULTS: The spatial analyses of excess mortality reveal a very heterogenous pattern, even within federal states. The coastal areas in the north were least affected, while the south of eastern Germany experienced the highest levels. Excess mortality in the most affected districts, with standardised mortality ratios reaching up to 20%, is driven widely by older ages and deaths reported in December, particularly from COVID-19 but also from cardiovascular and mental/nervous diseases. CONCLUSIONS: Our results suggest that increased psychosocial stress influenced the outcome of excess mortality in the most affected areas during the second lockdown, thus hinting at possible adverse effects of strict policy measures. It is essential to accelerate the collection of detailed mortality data to provide policymakers earlier with relevant information in times of crisis.

Different health systems - Different mortality outcomes? Regional disparities in avoidable mortality across German-speaking Europe, 1992-2019.

BACKGROUND: Evaluating the impact of health systems on premature mortality across different countries is a very challenging task, as it is hardly possible to disentangle it from the influence of contextual factors such as cultural differences. In this respect, the German-speaking area in Central Europe (Austria, Germany, South Tyrol and large parts of Switzerland) represents a unique 'natural experiment' setting: While being exposed to different health policies, they share a similar culture and language. METHODS: To assess the impact of different health systems on mortality differentials across the German-speaking area, we relied on the concept of avoidable mortality. Based on official mortality statistics, we aggregated causes of death below age 75 that are either 1) amenable to health care or 2) avoidable through primary prevention. We calculated standardised death rates and constructed cause-deleted life tables for 9 Austrian, 96 German, 1 Italian and 5 Swiss regions from 1992 to 2019, harmonised according to the current territorial borders. RESULTS: There are strong north-south and east-west gradients in amenable and preventable mortality across the studied regions to the advantage of the southwest. However, the Swiss regions still show significantly lower mortality levels than the neighbouring regions in southern Germany. Eliminating avoidable deaths from the life tables reduces spatial inequality in life expectancy in 2017/2019 by 30% for men and 28% for women. CONCLUSIONS: The efficiency of health policies in assuring timely and adequate health care and in preventing risk-relevant behaviour has room for improvement in all German regions, especially in the north, west and east, and in eastern Austria as well.

Effects of the COVID-19 pandemic on life expectancy and premature mortality in the German federal states in 2020 and 2021.

The mortality impact of COVID-19 has mainly been studied at the national level. However, looking at the aggregate impact of the pandemic at the country level masks heterogeneity at the subnational level. Subnational assessments are essential for the formulation of public health policies. This is especially important for federal countries with decentralised healthcare systems, such as Germany. Therefore, we assess geographical variation in the mortality impact of COVID-19 for the 16 German federal states in 2020 and 2021 and the sex differences therein. For this purpose, we adopted an ecological study design, using population-level mortality data by federal state, age, and sex, for 2005-2021 obtained from the German Federal Statistical Office. We quantified the impact of the pandemic using the excess mortality approach. We estimated period life expectancy losses (LE losses), excess premature mortality, and excess deaths by comparing their observed with their expected values. The expected mortality was based on projected age-specific mortality rates using the Lee-Carter methodology. Saxony was the most affected region in 2020 (LE loss 0.77 years, 95% CI 0.74;0.79) while Saarland was the least affected (-0.04, -0.09;0.003). In 2021, the regions with the highest losses were Thuringia (1.58, 1.54;1.62) and Saxony (1.57, 1.53;1.6) and the lowest in Schleswig-Holstein (0.13, 0.07;0.18). Furthermore, in 2021, eastern regions experienced higher LE losses (mean: 1.13, range: 0.85 years) than western territories (mean: 0.5, range: 0.72 years). The regional variation increased between 2020 and 2021, and was higher among males than among females, particularly in 2021. We observed an unequal distribution of the mortality impact of COVID-19 at the subnational level in Germany, particularly in 2021 among the male population. The observed differences between federal states might be partially explained by the heterogeneous spread of the virus in 2020 and by differences in the population's propensity to follow preventive guidelines.

Inhomogeneous Superconductivity Onset in FeSe Studied by Transport Properties.

Heterogeneous superconductivity onset is a common phenomenon in high-Tc superconductors of both the cuprate and iron-based families. It is manifested by a fairly wide transition from the metallic to zero-resistance states. Usually, in these strongly anisotropic materials, superconductivity (SC) first appears as isolated domains. This leads to anisotropic excess conductivity above Tc, and the transport measurements provide valuable information about the SC domain structure deep within the sample. In bulk samples, this anisotropic SC onset gives an approximate average shape of SC grains, while in thin samples, it also indicates the average size of SC grains. In this work, both interlayer and intralayer resistivity were measured as a function of temperature in FeSe samples of various thicknesses. To measure the interlayer resistivity, FeSe mesa structures oriented across the layers were fabricated using FIB. As the sample thickness decreases, a significant increase in superconducting transition temperature Tc is observed: Tc raises from 8 K in bulk material to 12 K in microbridges of thickness ∼40 nm. We applied analytical and numerical calculations to analyze these and earlier data and find the aspect ratio and size of the SC domains in FeSe consistent with our resistivity and diamagnetic response measurements. We propose a simple and fairly accurate method for estimating the aspect ratio of SC domains from Tc anisotropy in samples of various small thicknesses. The relationship between nematic and superconducting domains in FeSe is discussed. We also generalize the analytical formulas for conductivity in heterogeneous anisotropic superconductors to the case of elongated SC domains of two perpendicular orientations with equal volume fractions, corresponding to the nematic domain structure in various Fe-based superconductors.

Quantifying the contribution of smoking to regional mortality disparities in Germany: a cross-sectional study.

OBJECTIVES: Substantial regional variation in smoking behaviour in Germany has been well documented. However, little is known about how these regional differences in smoking affect regional mortality disparities. We aim to assess the contribution of smoking to regional mortality differentials in Germany over the last four decades. DESIGN: A cross-sectional study using official cause-specific mortality data by German Federal State aggregated into five macro-regions: East, North, South, West-I and West-II. PARTICIPANTS: The entire population of Germany stratified by sex, age and region during 1980-2019. MAIN OUTCOME MEASURES: Smoking-attributable fraction estimated using the Preston-Glei-Wilmoth method; life expectancy at birth before and after the elimination of smoking-attributable deaths. RESULTS: In all macro-regions, the burden of past smoking has been declining among men but growing rapidly among women. The hypothetical removal of smoking-attributable deaths would eliminate roughly half of the contemporary advantage in life expectancy of the vanguard region South over the other macro-regions, apart from the East. In the latter, smoking only explains around a quarter (0.5 years) of the 2-year difference in male life expectancy compared with the South observed in 2019. Among women, eliminating smoking-attributable deaths would put the East in a more disadvantageous position compared with the South as well as the other macro-regions. CONCLUSION: While regional differences in smoking histories explain large parts of the regional disparities in male mortality, they are playing an increasingly important role for female mortality trends and differentials. Health policies aiming at reducing regional inequalities should account for regional differences in past smoking behaviour.