Contribution of smoking-related and alcohol-related deaths to the gender gap in mortality: evidence from 30 European countries.

BACKGROUND: Women now outlive men throughout the globe, a mortality advantage that is very established in developed European countries. Debate continues about the causes of the gender gap, although smoking is known to have been a major contributor to the difference in the past.
OBJECTIVES: To compare the magnitude of the gender gap in all-cause mortality in 30 European countries and assess the contribution of smoking-related and alcohol-related deaths.
METHODS: Data on all-cause mortality, smoking-related mortality and alcohol-related mortality for 30 European countries were extracted from the World Health Organization Health for All database for the year closest to 2005. Rates were standardised by the direct method using the European population standard and were for all age groups. The proportion of the gender gap in all-cause mortality attributable to smoking-related and alcohol-related deaths was then calculated.
RESULTS: There was considerable variation in the magnitude of the male 'excess' of all-cause mortality across Europe, ranging from 188 per 100, 000 per year in Iceland to 942 per 100, 000 per year in Ukraine. Smoking-related deaths accounted for around 40% to 60% of the gender gap, while alcohol-related mortality typically accounted for 20% to 30% of the gender gap in Eastern Europe and 10% to 20% elsewhere in Europe.
CONCLUSIONS: Smoking continues to be the most important cause of gender differences in mortality across Europe, but its importance as an explanation for this difference is often overshadowed by presumptions about other explanations. Changes in smoking patterns by gender suggest that the gender gap in mortality will diminish in the coming decades.

Introduction

Since the late 1990s there has been evidence that women now outlive men in all countries of the world.1 Historical records show that in Sweden, Denmark, Italy, The Netherlands, England and Wales, the life expectancy of women has exceeded that of men since the mid to late 18th century, and there has been speculation about the causes of gender differences since that time.2 Different explanations have been postulated for this gender gap, including biological factors. However, there is considerable variability, and sometimes rapid change,3 in the magnitude of the female mortality advantage over time and in different countries, a variability that poses challenges for simple biological explanations for the gender gap. Earlier research suggested that health behaviours, and particularly men's higher prevalence of smoking, were a major cause of gender differences in the US.4 Here, we use contemporary mortality data for 30 European countries to examine the extent to which men's higher mortality can be explained by smoking-related and alcohol-related deaths.

Methods

All-cause mortality, smoking-related mortality (defined as cancers of the respiratory tract, ischaemic heart disease, cerebrovascular disease and chronic obstructive pulmonary disease; International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) codes C00–C14, C32–C34, C15, I20–I25, I60–I69 and J40–J47) and alcohol-related mortality (defined as cancers of the oesophagus and larynx, alcohol dependence syndrome, alcohol psychosis, chronic liver disease, liver cirrhosis and external causes; ICD10 codes C15, C32, F10, K70, K73, K74, V00–V99, W00–W99, X00–X99 and Y00–Y99) were extracted from the World Health Organization Health for All (WHO-HFA) database.5

All death rates were standardised by the direct method using the European population standard and were for all age groups. Data were used for the year closest to 2005 (range 2003/2004 to 2006). The proportion of the gender gap in all-cause mortality that was smoking-related and alcohol-related was calculated for each country as the gender gap for each cause divided by the gender gap for all causes.

Results

Although all-cause death rates are higher for men than for women in all countries, there continues to be considerable variation in the extent of the gender difference in contemporary Europe. The gender gap in all-cause death rates varied from 188 (per 100 000 per year) ‘excess’ deaths among men in Iceland to 942 in Ukraine (see table 1). The gender gap showed some geographical patterning such that all of the countries with a gender gap in excess of 400 per 100 000 per year were located in Eastern Europe. Three Northern European countries (Iceland, UK and Sweden) and two Mediterranean countries (Greece and Cyprus) had a gender mortality gap of 230 per 100 000 per year or less. Outside the former Soviet block, Belgium (323 per 100 000 per year), Spain (332), France (336), Finland (362) and Portugal (367) had the highest gender gaps in all-cause mortality.

Table 1

The proportion of the gender gap in mortality related to alcohol and smoking ordered by the all-cause mortality gender gap (2003–2005)

*All mortality rates are deaths per 100,000 population per year.

**All gender gaps are calculated by subtracting the female from the male rate.

There was a fivefold difference between the countries with the lowest (Iceland: 97 per 100 000) and highest (Ukraine: 495 per 100 000) gender gap in smoking-related deaths. Despite this variation, smoking-related deaths accounted for between 40% and 60% of the gender gap in all countries except Denmark (39%), Portugal (38%) and France (38%), where smoking-related deaths accounted for a slightly lower proportion, and Malta (74%), where smoking-related deaths accounted for a higher proportion (see table 1). Smoking-related mortality was high in men and women in Eastern European countries where the absolute difference in the gap was also high.

There was an eightfold difference between the countries with the lowest (Iceland: 29 per 100 000) and highest (Lithuania: 253 per 100 000) gender gap in alcohol-related deaths. As expected,6 alcohol-related deaths were particularly high in men in the Eastern European countries (where the rates for women were also high in comparison with other European countries). Alcohol-related deaths also accounted for a substantial proportion of the gender gap in all-cause mortality (typically for around 20%), although the proportion tended to be higher in Eastern Europe. Despite large gender differences in alcohol consumption across societies and the huge variation in alcohol-related deaths across Europe, the contribution of smoking-related mortality to the gender gap in all-cause mortality was greater than that for alcohol-related mortality in all countries examined (see table 1).

Discussion

Mortality is higher in men than women across Europe, but there is considerable variation in the magnitude of this gap (from an ‘excess’ of 188 deaths per 100 000 per year in Iceland to 942 per 100 000 per year in Ukraine). Smoking-related deaths accounted for around 40% to 60% of the gender gap, while alcohol-related mortality typically accounted for around 20% of the gender gap. The range in the contribution of smoking-related deaths reflects gender differences in the uptake of smoking by gender in earlier decades.7

The strengths of this analysis are the use of best available data from the WHO (who endeavour to quality assure the data) and the inclusion of most large European countries (with the exception of Turkey). There are, however, also some limitations to consider. First, alcohol and tobacco use contribute to some shared causes of mortality and morbidity and so any division into alcohol-related and smoking-related causes will underestimate the scope of influence of each on mortality. For example, liver cancer has been linked with excessive alcohol consumption for some time, but more recently smoking has been also shown to be associated with this malignancy. Similarly, tobacco and alcohol consumption contribute to the development of cancers of the aerodigestive tract.8 This is the rationale behind ‘Peto's method’ of benchmarking smoking-related deaths within each country against lung cancer deaths,9 as one method of estimating smoking related deaths. The WHO's definitions acknowledge that smoking and alcohol contribute to some causes of death (oesophageal and throat cancer) but not others. Unfortunately, the cause-specific data required for applying any alternative definitions were not available from the WHO-HFA database and so we were constrained by the WHO's definitions. A second limitation is the potential for differential coding practices to bias the cause-specific death rates between countries despite the use of the International Classification of Diseases system. Third, the WHO-HFA database only provides these data by gender for all ages together so we were unable to examine relationships in specific age groups.

It is no surprise that two of the most important health behaviours, smoking and hazardous drinking continue to account for substantial proportions of the gender gap in mortality because health behaviours have long been a powerful way of portraying gendered identities.10–15 For example, it has been suggested that cultural portrayals of drinking keep shifting to maintain a gendered distinction in drinking behaviours, so that as men and women both modify their drinking behaviours, considerable effort is devoted to constructing men's drinking in different ways to women's drinking.16 The balance of the contribution of smoking-related and alcohol-related deaths and the degree of consistency of the pattern across Europe is perhaps more of a surprise given the complexity of associations between gender, smoking and drinking over the preceding decades, the long lag time between exposure to smoking and disease (estimated to be between 20 and 35 years for lung cancer,17 and 30 to 40 years for other cancers such as colorectal cancer18), the considerable variation in the magnitude of the gender gap in all-cause mortality and the different stages in the smoking epidemic that countries of Northern, Western, Southern and Eastern Europe have reached. What is clear is that smoking accounts for a substantial part of the gender difference in mortality in contemporary Europe. The importance of health behaviours (and in particular smoking) in accounting for a large proportion of the gender gap in mortality is often lost in discussion of gender and health. For example, it is often suggested that other factors (such as differences in consultation for illness) account for much of this difference (see for example White and Witty19) despite a paucity of robust evidence.20

The continuing uptake of smoking among a significant minority of young people, and increases in detrimental patterns of alcohol consumption, point to the ongoing need for public health measures to reduce health-damaging behaviours. However, the continuing links between smoking and drinking and cultural constructions of gender demonstrate that action to reduce smoking and harmful drinking cannot be tackled at an individualistic level alone. These behaviours are culturally bound and these cultural constructions of behaviours are partially shaped by and exploited by the alcohol and tobacco industries (see for example Amos and Haglund, and Toll and Ling11 21), in addition to people's structural opportunities and constraints.22

Profound changes in the population level of smoking and in the magnitude of the gender gap in smoking should contribute to smaller gender differences in mortality in coming decades, beginning first in countries in Western and Northern Europe that reached the fourth stage of the tobacco epidemic first.7 However, the extent to which this is realised will depend on the ways in which other health risk behaviours are patterned by gender.

This study uses contemporary data to examine the contribution of smoking-related and alcohol-related mortality to the gender gap in all-cause mortality in 30 European countries.

Despite large variation in the magnitude of the gender gap in all-cause mortality in these countries in 2005 and the fact that the countries are at different stages of the smoking epidemic, smoking-related deaths accounted for a large proportion of the gender gap in all countries examined (typically 40% to 60%).

It may still be several decades before profound changes in gender differences in smoking in some of these countries are reflected in a smaller contribution of smoking-related deaths to a reduced gender gap in mortality.