Germany has a powerful tobacco industry, which influences Government policy against tobacco control measures. Prices are among the lowest in the European Union and women have been targeted with strong promotional images. Smoking rates have increased sharply in the former East Germany, particularly among younger adult women. The most deprived German women are most likely to smoke, further increasing their burden of ill health.

How many women smoke or use tobacco?

• Nearly a third of German women smoke; 30.6% women vs. 38.9% men. This is higher compared to the 25% female average in the western WHO-Europe Region.
• A fifth or 20.6%, continue to smoke during pregnancy. Income differences show that 39.5% of poorest women continue to smoke during pregnancy vs. 24% of pregnant women with the highest socioeconomic status. Similar smoking rates are seen among the poorest mothers where 46.8% smoke vs. 28.4% of the wealthiest.
• Since 1992, smoking rates among German women rose by 0.7% among those aged 25-69. This increase was especially apparent in the former East Germany, where smoking rates rose up by 42% during 1992-98; mainly due to sharp increases among those between the ages of 25-49.
• Younger women are more likely to smoke. Nearly half, or 44%, of those between the ages of 18-24 smoke which is more than double the smoking rate at among those between 50-59.
• Smoking increases with deprivation across the social groups. There are clear links of patterns of increased smoking with poor education, low job status, unemployment, living on social welfare and divorce. Poor education is the best predictor of smoking uptake for women under fifty.
• Among women aged 25 to 34, the smoking rate of poor women is roughly double the rate seen among those with the highest socioeconomic status. The poor vs. wealthy female smoking rates are 55% vs. 25% in old Lander and 56% vs. 27% in the former GDR.

Smoking among young women

• German girls typically start to smoke at around age 13-14.
• In Germany, smoking among adolescents has been increasing. Since 1998, the smoking rates among 15 year olds increased from 19% to 23% for boys and from 16% to 25% for girls.
• Nearly 28% of girls aged 12-17 smoke vs. 27% of boys. Although there is a small difference in these rates, the youngest girls in this age group have been more likely to smoke than boys since 1997. Smoking among young women aged 12-17 decreased continuously until 1989 then increased in 1993 to 21% and again in 2001 to 27%.
• Bavarian data suggest that smoking among girls aged 12-14 has nearly tripled since 1995 from 4.3% to 11.9% seen today.
• Among the 12-17 year old girls who smoke, nearly half or 39%, smoke 1-5 cigarettes a day and 13% are heavy smokers consuming more than 20 cigarettes a day. Daily smoking suggests that these young women are likely to be as nicotine dependent as adult smokers.
• Compared to younger smokers, the difference between smoking among girls and boys aged 18-25 increases where 42% of the young women and 46% of the young men smoke. Smoking among women between the ages of 18-25 continues to decrease slowly each year.
• In the 1990s, German ads promoted smoking as ‘liberated’ for women which helps to explain why smoking at age 12-25 nearly doubled in former East Germany and desire to quit fell sharply.

Health risks

• Around 42,100 of women in Germany die each year as a direct result of smoking. This is equivalent to over a hundred deaths a day.
• It is estimated that smoking is responsible for 21.5% of deaths from coronary diseases and for up to 60% of lung cancer deaths among women.
• The death rate from lung cancer has increased steadily, up nearly a third since 1990, while the male rate has declined. More specifically, the increase has been 22% for those aged 45-55, 33% for those aged 55-64 and nearly half, 45% for those aged 65-74.

Tobacco control

• Since 1992, nongovernmental organizations such as the German Medical Action Group and German Smokefree Alliance have built the German Coalition against Smoking which played a major role in developing advocacy and communication strategies. In 2003, the name was changed to Action Group Nonsmoking. Germany also has a powerful tobacco industry, with many political allies.
• The German Cancer Research Center was developed in partnership with 30 experts in medicine, public health and communication. This Center created a Unit Cancer Prevention which was recognized as a WHO Collaborating Centre for Tobacco Control in 2002. Aims and the work plan include strong support for the FCTC, building capacity in German speaking countries for tobacco control including German publications.
• The “Recommendations for effective tobacco control policies” developed in 2002, are the basis for NGO`s Action Plans, which aim to increase taxes, create a tobacco free society, instill a complete ban on tobacco advertising and vending machines, implement more stringent product regulation standards and promote health through mass media campaigns.
• This Center published Factsheets about “Ban of tobacco advertising”, “Tobacco tax increases”, “Smoking and social inequalities” and “Passive smoking of children in Germany” which are available at www.tabakkontrolle.de
• National policies on smoking include commitments to restrict youth access to tobacco products and to improve smokefree provisions.
• A new policy was passed in 2001 to protect non-smokers from passive smoking or environmental tobacco smoke (ETS) at work. All major railway stations are designated smokefree, but this law is not yet properly enforced.
• Since 2000, there has been a consistent increase in real price of cigarettes. However a pack ‘costs’ only seventeen minutes of average labour. Further price increases are to be introduced in December 2004 and in 2005.
• Tobacco promotions on German TV and radio are banned, but otherwise there are few advertising restrictions. Targeted promotions often include distribution of free samples in streets, bars and night-clubs.
• An EU Directive includes a ban on use of misleading terms ‘light’ and ‘mild’, which appealed particularly to women. The directive is also realized in Germany.
• Germany signed the FCTC in October 2003, ratification is in progress.

Education and support to quit

• The 2001 “European week against cancer” included a campaign for German women, highlighting the impact of smoking on appearance and risk during pregnancy.
• Support for German smokers is available through primary care, pharmacies and clinics. Specific training is available to health workers although most services are local and not evaluated.
• Specific materials have been developed for gynaecologists to support pregnant smokers, however relapse rates after the baby is born remain high.
• The WHO ‘Partnership project to reduce tobacco dependence’ is developing initiatives at pilot sites in German workplaces, schools and hospitals.
• Quit and Win competitions and the German Quitline have been popular and successful. Participation in the Quit and Win contest has been increasing each year from 25,000 participants in 2000 to more than 90,000 in 2004.
• Most nicotine replacement therapy (NRT) is available to German adults without prescription.
  
  13 July 2004

For more information

• WHO-Collaboration Centre for Tobacco Control – www.tabakkontrolle.de/publikations
• Bundeszentrale für gesundheitliche Aufklärung – http://www.bzga.de
• Action Group Nonsmoking – http://www.weltnichtrauchertag.de/html/koalition
  _geg__rauchen.html
• Deutsche Hauptstelle gegen Suchtgefahren – http://www.dhs.de/
• “Women and Smoking: a Report of the Surgeon General”
  US Dept of Health and Human Services. 2001
• “Women and the Tobacco Epidemic” WHO Geneva: World Health Organisation. 2001