Socioeconomic inequalities in smoking prevalence and intensity in Germany: A repeated cross-sectional analysis from 1998 to 2024

Background: Smoking inequalities by socioeconomic position (SEP) have widened consistently in Germany, but sex-specific trends beyond 2013 and inequalities in daily cigarette consumption among smokers (intensity) are unknown. We analyzed trends in absolute and relative socioeconomic inequalities in smoking prevalence and intensity among German adults across three decades. Methods: We used 14 waves (1998-2024) of population-representative cross-sectional data from the German Socio-Economic Panel to estimate sex-specific trends in smoking prevalence and intensity in adults aged 25-64. Inequalities were quantified across strata of education, occupation, and equivalized household income using the absolute and relative concentration index with 95% bootstrap confidence intervals. Results: Smoking prevalence declined from 35.05% (CI: 33.90%, 36.20% in 1998 to 22.19% (CI: 21.15%, 23.24%) in 2024, and mean intensity from 18 (CI: 17,18) to 13 (CI: 13, 14) cigarettes/day. Over this period sex-differences in both outcomes narrowed almost completely. Absolute and relative inequalities in smoking prevalence widened particularly for education and occupation. By 2024, the inequality gap between men and women has largely narrowed driven by a stagnating or rising smoking prevalence among low-SEP women (at least until 2018) alongside continued declines in higher-SEP women and for men. In fact, relative educational inequalities are now larger among women. Inequalities in smoking intensity, particularly related to income, were generally smaller than those in prevalence. Conclusion: Socioeconomic smoking inequalities in Germany widened from 1998 to 2024 primarily driven by reductions among higher-SEP groups and increases in low-SEP women. Health equity must be considered in the German tobacco control strategy.