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This article examines educational differences in the prevalence of behavioural risk factors among adults and compares the results for Germany with the average from the European Union (EU). Data were derived from the second wave of the European Health Interview Survey, which took place between 2013 and 2015 (EHIS 2). Analyses were conducted using a regression-based calculation of relative and absolute educational differences in the prevalence of behavioural risk factors, based on self-reported data from women and men aged between 25 and 69 (n=217,215). Current smoking, obesity, physical activity lasting less than 150 minutes per week, heavy episodic drinking and non-daily fruit or vegetable intake are more prevalent among people with a low education level than those with a high education level. This applies to Germany as well as the EU average. Overall, the relative educational differences identified for these risk factors place Germany in the mid-range compared to the EU average. However, relative educational differences in current smoking and heavy episodic drinking are more manifest among women in Germany than the EU average, with the same applying to low physical activity among men. In contrast, relative educational differences in non-daily fruit or vegetable intake are less pronounced among women and men in Germany than the average across the EU. Increased efforts are needed in various policy fields to improve the structural conditions underlying health behaviour, particularly for socially disadvantaged groups, and increase health equity.

Following the fall of the Berlin Wall in November 1989, considerable effort was made to bring the living conditions and levels of social participation in the former East German federal states into line with the former West German federal states. As a result, differences in health between the East and the West diminished significantly, in many cases as early as the 1990s, examples being life expectancy and cardiovascular mortality. In regard to health behaviour, the overall tendency has also clearly been one of convergence. Thus, only very small differences can be observed today, for example in the use of tobacco or in the prevalence of obesity. Yet the results also highlight the insufficiency of regarding the remaining differences as a simple comparison between East and West. Instead, the focus should shift towards smaller-scale approaches that take regional differences in living conditions into account.

Objective: Despite extensive study of the obesity epidemic, research on whether obesity has risen faster in lower or in higher socioeconomic groups is inconsistent. This study examined secular trends in obesity prevalence by socioeconomic position and the resulting obesity inequalities in the German adult population. Methods: Data were drawn from three national examination surveys conducted in 1990–1992, 1997–1999 and 2008–2011 (n = 18,541; age range: 25–69 years). Obesity was defined by a body mass index ≥30 kg/m2 using standardised measurements of body height and weight. Education and equivalised household disposable income were used as indicators of socioeconomic position. Time trends in socioeconomic inequalities in obesity were examined using linear probability and log-binomial regression models. Results: In each survey period, the highest socioeconomic groups had the lowest prevalence of obesity. The low and medium socioeconomic groups showed increases in obesity prevalence, whereas no such trend was observed in the high socioeconomic groups. Absolute inequalities in obesity by income increased by an average of 0.53 percentage points per year (95% confidence interval [CI] 0.01–1.05, p = 0.047) among men and 0.47 percentage points per year (95% CI 0.05–0.90, p = 0.029) among women. Absolute inequalities in obesity by education increased on average by 0.64 percentage points per year (95% CI 0.19–1.08, p = 0.005) among women but not among men (0.33 percentage points, 95% CI –0.27 to 0.92, p = 0.283). Conclusions: These findings suggest a widening obesity gap between the top and the bottom of the socioeconomic spectrum. This has the potential to have adverse consequences for population health and health inequalities in coming decades. Interventions that are effective in preventing and reducing obesity in socially disadvantaged groups are needed.

This study examines the extent to which health inequalities among children and adolescents in Germany have developed over the past decade. The analyses are based on data from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), which are representative of the 0- to 17-year-old population in Germany. The KiGGS data were collected in three waves: the KiGGS baseline study (2003-2006), KiGGS Wave 1 (2009-2012) and KiGGS Wave 2 (2014-2017). Prevalences of five health outcomes are considered: general health, mental health problems, physical activity, the consumption of sugary soft drinks, and smoking. Moreover, it defines health inequalities in relation to differences in the socioeconomic status of the family (SES), an index derived from the parents’ level of education, occupation and income, and considers both absolute and relative health inequalities. In order to do so, the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII) were calculated using linear probability or log-binomial models. Significant inequalities were identified to the detriment of young people from families with a low SES. These inequalities were particularly pronounced in the KiGGS Wave 2 data with regard to general health and the consumption of sugary soft drinks. Additionally, evidence from trend analyses for these two outcomes suggests that relative inequalities have increased. However, absolute inequalities decreased during the same period, and this also applies to smoking. The persistently high and, in some cases, widened levels of health inequalities indicate that adolescents from families with a low SES do not benefit to the same extent from disease prevention and health promotion measures for children and adolescents as young people from families with a higher SES.

Oral health behaviour plays a key role in the prevention of caries and periodontitis. This article describes the prevalence, determinants and trends of tooth brushing frequency and utilization of dental check-ups. The analyses are based on the data from the second wave of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS Wave 2, 2014-2017). The results show that around 80% of children and adolescents meet the recommended tooth brushing frequency and utilization of dental check-ups. Around one fifth of children and adolescents do not meet the recommendations. 14- to 17-year-old adolescents, as well as those with low socioeconomic status and a migration background are groups which are particularly at risk. Compared to the KiGGS baseline study (2003-2006), tooth brushing frequency and utilization of dental check-ups has improved. While this positive development is apparent for nearly all the population groups analysed, the same risk groups that were identified by the baseline study are also evident in the KiGGS Wave 2 results. Targeted measures directed at specific target groups to promote oral health behaviour at younger ages should therefore be maintained and expanded, respectively.

Data from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) enable conclusions about the utilization of outpatient and inpatient medical services by children and adolescents accounting the family’s socioeconomic status (SES). Results from the second follow-up to the KiGGS survey (KiGGS Wave 2), which covers the years 2014 to 2017, clearly demonstrate that children and adolescents from families with a low SES visit specialists in general medicine, gynaecologists and psychiatrists, as well as child and adolescent psychiatrists, psychotherapists and psychologists more frequently. In contrast, children and adolescents from families with a high SES visit paediatric, dermatological, dental and orthodontic practices more often. No statistically significant differences between the status groups with regard to the utilization of outpatient medical services in hospitals were identified. However, children and adolescents from the low status group received inpatient hospital treatment more frequently and, on average, spent more nights in hospital. These results reflect status-specific differences both in disease prevalence and care, as well as in patterns related to the utilization of medical services.

Examinations for early detection of diseases (called U-Untersuchungen in Germany) are among the most important prevention measures at childhood age. According to KiGGS Wave 2 data, participation rates are over 95% for most of these examinations. 99.7% and 99.6% of children, respectively, who had reached the recommended age for these examinations participated in the U1 and U2 examinations, 98.0% and 98.1%, respectively, the U8 and U9 examinations. Participation rates for children from families with low socioeconomic status and those with a two-sided migration background are slightly lower. A comparison with previous KiGGS waves shows that the utilization of early detection examinations has increased significantly over the last ten years. During this time, social differences which were previously pronounced have decreased.

Attention deficit/hyperactivity disorder (ADHD) is one of the most common mental disorders in childhood and adolescence and is associated with functional, psychosocial and cognitive impairment. As part of the second wave of the German Health Interview and Examination Survey for Children and Adolescents (2014-2017), parents of children and adolescents aged between 3 and 17 years reported whether their child was diagnosed with ADHD by a physician or psychologist. Overall, 4.4% of children and adolescents have been diagnosed with ADHD in Germany. In comparison, the KiGGS baseline study (2003-2006) showed a reduction of lifetime ADHD diagnoses of almost one percentage point over a period of ten years. The reduction of parent-reported ADHD diagnoses primarily occurred among 3- to 8-year old children and boys. The results are discussed in terms of health promotion and the introduction of health care measures.

The close link between socioeconomic status (SES) and health can already be observed in childhood and adolescence. Although the vast majority of children and adolescents grow up healthily in Germany, social inequalities in health exist. The results of the second wave of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS Wave 2) demonstrate that children and adolescents with a low SES have a poorer level of general health and face health constraints more frequently than their peers with a higher SES. Social inequalities in mental health are significantly more profound than in the 12-month prevalence of bronchial asthma and allergic rhinitis. The odds of being affected by mental health problems or attention-deficit/hyperactivity disorder (ADHD) were 2.8 to 4.4 times higher for children and adolescents with a low SES compared to their peers with a high SES. Therefore, in order to enable all children and adolescents to grow up healthily, health promotion and disease prevention measures need to be put in place early in a child’s life and need to be tailored to the needs of particular target groups.

Passive smoking is associated with the same consequences for health as smoking, albeit to a lesser extent. Various legislative measures have been put in place in Germany to lower exposure to passive smoking. According to data from GEDA 2014/2015-EHIS, 11.3% of non-smoking adults are regularly exposed to passive smoking in enclosed spaces, this is particularly the case with young adults. Non-smoking women who are regularly exposed to passive smoking usually come into contact with passive smoking when they are together with friends and acquaintances (51.2%). Non-smoking men most frequently face passive smoking in the work place (56.1%). People with a high level of education are much less frequently exposed to passive smoking than those with medium to lower levels of education. Action still needs to be taken to protect people against the dangers linked to passive smoking.

Childhood and adolescence are key determining stages for health behaviour in the life course. Frequently, health-related attitudes and patterns of behaviour that develop at young age are also maintained at adult age. As studies show, already during childhood and adolescence, patterns of health risk behaviour are more common in certain population groups. KiGGS Wave 2 results confirm that 3- to 17-year-old children and adolescents from families with low socioeconomic status (SES) eat a less healthy diet, do fewer sports and are more often overweight or obese than their peers from more affluent backgrounds. Whereas socioeconomic differences appear to have little effect on levels of alcohol consumption among 11- to 17 year-olds, girls and boys with low SES smoke more frequently than their peers with high SES. Prevention and health promotion encourage children and adolescents to adopt healthy lifestyles, and aim to drive structural changes to stimulate behaviour which promotes good health. Combining measures that target individual behaviour and a settings-based approach appears to be the most promising preventative approach to reduce health inequalities among young people. Due to the clear impacts of socioeconomic differences on health behaviour already at young age measures for disadvantaged children and adolescents and their living conditions should be given an even stronger focus in the future.

Tobacco and alcohol use are among the leading preventable risk factors associated with premature mortality and a variety of diseases that have long-term effects. Although tobacco and alcohol use among adults is widespread in Germany, there is a trend towards lower levels of consumption. The foundations for health-related behaviour in adulthood are set at an early age: young people who use alcohol and tobacco also tend to do so regularly when they reach adulthood. With this in mind, health policies should focus on preventing young people from smoking, and encouraging them to adopt a responsible, low-risk approach to alcohol. This article analyses patterns of tobacco and alcohol use among children and adolescents (aged between 11 and 17 years). It describes the prevalences of tobacco and alcohol use, as well as trends and correlates. The data used in this article was sourced from the second follow-up to the German Health Interview and Examination Survey for Children and Adolescents (KiGGS Wave 2). The survey’s results show that 7.2% of 11- to 17-year-old children and adolescents smoke at least occasionally, with 3.7% doing so daily. The survey also demonstrates that a good half (51.0%) of 11- to 17-year-olds have ever drunk alcohol; at-risk drinking was prevalent among 12.1%, and heavy episodic drinking among 7.0%. The consumption of tobacco and alcohol increases considerably with age. Patterns of at-risk drinking and heavy episodic drinking show gender-associated differences: While more girls than boys practice at-risk drinking, more boys than girls practice heavy episodic drinking. Nevertheless, the KiGGS survey waves demonstrate a highly significant trend towards a decline in tobacco use (KiGGS baseline study 21.4%, KiGGS Wave 1 12.4%). The proportion of 11- to 17-year-olds who have ever drunk alcohol is also declining (KiGGS baseline study 63.9%, KiGGS Wave 1 55.6%). The proportions of at-risk drinking (KiGGS Wave 1 16.5%) and heavy episodic drinking (KiGGS Wave 1 12.0%) decreased as well. The results presented here are in line with findings from other studies that have surveyed adolescent tobacco and alcohol use in Germany, and they underscore the success of preventive measures.

The term ‘subjective health’ reflects not only existing illnesses and health complaints, but particularly emphasizes the personal well-being. Studies often collect data on subjective health by asking participants to provide self-assessments of their general state of health. This was also the case with GEDA 2014/2015-EHIS, which employed the internationally renowned Minimum European Health Module (MEHM) as part of the study. Its results demonstrate that 68.2% of adults in Germany rate their general health as very good or good, with the remaining 31.8% rating it as fair, poor or very poor. The proportion of women who rate their general health as very good or good is slightly lower than the proportion of men who do so (66.6% compared to 69.9%). With increasing age, women and men view the condition of their general health as worsening. The study also identified educational differences which showed that men and women with low levels of education tend to rate their health worse compared to self-assessments provided by women and men with higher levels of education, and in some cases also regional differences.

Abstract Objective Time trends in health inequalities have scarcely been studied in Germany as only few national data have been available. In this paper, we explore trends in socioeconomic inequalities in the prevalence of chronic illness using Germany-wide data from four cross-sectional health surveys conducted between 2003 and 2012 (n = 54,197; ages 25–69 years). We thereby expand a prior analysis on post-millennial inequality trends in behavioural risk factors by turning the focus to chronic illness as the outcome measure. The regression-based slope index of inequality (SII) and relative index of inequality (RII) were calculated to estimate the extent of absolute and relative socioeconomic inequalities in chronic illness, respectively. Results The results for men revealed a significant increase in the extent of socioeconomic inequalities in chronic illness between 2003 and 2012 on both the absolute and relative scales (SII2003 = 0.06, SII2012 = 0.17, p-trend = 0.013; RII2003 = 1.18, RII2012 = 1.57, p-trend = 0.013). In women, similar increases in socioeconomic inequalities in chronic illness were found (SII2003 = 0.05, SII2012 = 0.14, p-trend = 0.022; RII2003 = 1.14, RII2012 = 1.40, p-trend = 0.021). Whereas in men this trend was driven by an increasing prevalence of chronic illness in the low socioeconomic group, the trend in women was predominantly the result of a declining prevalence in the high socioeconomic group.

Maternal smoking during pregnancy poses a significant risk to the development of unborn children. Data from KiGGS Wave 2 shows that 10.9% of mothers of 0 to 6 year-old children smoked during pregnancy. Mothers who were under 25 when giving birth smoked about two to three times more often than older mothers. Furthermore, there is a distinct social gradient in maternal smoking: a higher socioeconomic status is associated with a lower proportion of children with a mother who smoked during pregnancy. A comparison with data from the KiGGS baseline study shows that the proportion of mothers who smoked during pregnancy fell from to 19.9% to 10.9% between the two study periods. Thus, the KiGGS results are in line with those from the perinatal survey, which also found that the proportion of pregnant women who smoke has declined significantly since the mid-1990s.

Data from KiGGS Wave 2 show that 95.7% of parents who participated in the survey rated the overall health of their 3 to 17 year-old children as very good or good. This proportion is higher than the figures identified by the KiGGS baseline study across all age groups. The proportion of children rated as in very good health is highest among 3 to 6 year-olds and decreases with age. Among 14 to 17 year-olds, the proportion of girls in very good health is well below the level found among boys. A pronounced social gradient is still clear from the data: the proportion of parents who assess the overall health of their children as very good or good rises with increasing social status. This highlights the need for strategies to reduce health inequalities that involve society as a whole, and the need for target group-specific measures in prevention and health promotion.

This article describes the method applied to measure socioeconomic status (SES) and subjective social status (SSS) in the current wave of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS Wave 2), which was conducted over three years between 2014 and 2017. The composite multidimensional SES index was calculated as a sum of point scores for the parents’ education level, occupational status and equivalised disposable income. SSS was assessed in the 11 to 17 year age group using a German version of the MacArthur Scale for children and adolescents. To demonstrate the use of both instruments, we present examples that highlight the association between SES and SSS with the general health of children and adolescents in the 3 to 17 and/or 11 to 17 age groups. Over 95% of parents rated the general health of their children as ‘very good’ or ‘good’. However, the analyses clearly reveal that children and adolescents from families with low SES and SSS have poorer general health than their better-off peers. Even when mutually adjusted, both low SES and SSS are independently associated with poorer general health. In addition to the SES index, studies on the health of children and adolescents should therefore also consider SSS. In this way, additional aspects of the socioeconomic conditions of families can be taken into account.

Social epidemiological research has consistently demonstrated that people with a low socioeconomic status are particularly at risk of diseases, health complaints and functional limitations, and die at younger ages than those with a higher socioeconomic status. Greater stresses and strains in the workplace, family and living environment are under discussion as possible explanations. Health-related behaviours, psycho-social factors and personal resources, which are important in coping with everyday demands, certainly also play a role. From a public health and health policy perspective, reducing these health inequalities is an important goal. Insights into developments and trends in health inequalities over time can contribute towards highlighting new and emerging problems, and can thus help identify possible target groups and settings for relevant interventions. At the same time, these insights provide a basis upon which the success of policies and programmes that have already been implemented can be analysed and measured. Against this background, this review examines how health inequalities in Germany have developed over the last 20 to 30 years and places its findings within the context of the latest international research in this field.

Smoking behaviour during adolescence is particularly important because the pattern of a person’s tobacco consumption in later life usually is established in this period. According to recent data from KiGGS Wave 2, 7.4% of 11 to 17 year-old girls and 7.0% of boys of the same age smoke at least occasionally. The proportion of children and adolescents who smoke increases with age. Adolescents with high socioeconomic status smoke less frequently than their peers with medium or low socioeconomic status. Since the beginning of the first KiGGS study (2003-2006), the proportion of 11 to 17 year-olds who smoke fell from 21.4% to 12.4% (2009-2012) and has recently dropped to 7.2% (2014-2017). Despite considerable progress, however, there is still potential to improve tobacco prevention policy in Germany for example using taxation and advertising bans.

Abstract Background Social inequalities in health can be explained in part by the social patterning of leisure-time physical activity, such as non-participation in sports. This study is the first to explore whether absolute and relative educational inequalities in sporting inactivity among adults have changed in Germany since the early 2000s. Methods Data from four cross-sectional national health surveys conducted in 2003 (n = 6890), 2009 (n = 16,418), 2010 (n = 17,145) and 2012 (n = 13,744) were analysed. The study population was aged 25–69 years in each survey. Sporting inactivity was defined as no sports participation during the preceding 3 months. The regression-based Slope Index of Inequality (SII) and Relative Index of Inequality (RII) were calculated to estimate the extent of absolute and relative educational inequalities in sporting inactivity, respectively. Results Sporting inactivity was consistently more prevalent in less-educated groups. The overall prevalence of sporting inactivity declined significantly over time. However, the decline was observed only in the high and medium education groups, while no change was observed in the low education group. Both absolute and relative educational inequalities in sporting inactivity were found to have widened significantly between 2003 (SII = 0.30, 95% CI = 0.25–0.35; RII = 2.08, 95% CI = 1.83–2.38) and 2012 (SII = 0.41, 95% CI = 0.37–0.45; RII = 3.44, 95% CI = 3.03–3.91). Interaction analysis showed that these increases in inequalities were larger in the younger population under the age of 50 than among the elderly. Conclusions The findings suggest that the gap in sports participation between adults with high and low educational attainment has widened in both absolute and relative terms because of an increase in sports participation among the better educated. Health-enhancing physical activity interventions specifically targeted to less-educated younger adults are needed to prevent future increases in social inequalities in health.

Based on data from the tobacco tax revenue statistics provided by Germany’s Federal Statistical Office, we analyse the development of sales of various tobacco products. In 2016, per capita consumption of tobacco products taxed in Germany was 918 manufactured cigarettes, 37 cigars/cigarillos, 308 g fine cut (equivalent to 462 cigarettes), and 31 g of (water) pipe tobacco. Between 1991 and 2016, the sale of manufactured cigarettes decreased by nearly half, while the sale of fine cut increased by around two thirds. If the amount of fine cut is expressed as cigarette equivalents (whereby 1kg of fine cut equals 1,500 cigarettes) and added to the number of manufactured cigarettes sold, then cigarette sales have decreased by one third since 1991. Numerous facts indicate that measures implemented in the context of a more restrictive tobacco control policy, such as tax increases and smoking bans, have contributed to this decrease in tobacco sales.

Consuming harmful amounts of alcohol is considered a contributing factor in over 200 diseases. Heavy episodic drinking is a particularly risky drinking pattern, with possible consequences such as acute alcohol intoxication, injuries and violence. GEDA 2014/2015-EHIS defines heavy episodic drinking as the consumption of six or more alcoholic beverages on one occasion at least once per month. 24.9% of women and 42.6% of men show this drinking pattern at least once per month. Regular heavy episodic drinking is most common among 18- to 29-year-olds. The prevalence of heavy episodic drinking among highly educated women (all age groups) and men (aged over 45) is lower than it is among those with lower levels of education. The prevention of harmful levels of alcohol consumption requires measures including social and environmental interventions as well as targeting the individual behaviour which are focused on young adults as well as the diverse drinking patterns seen among groups with different levels of education.

Consuming harmful amounts of alcohol is considered a contributing factor in over 200 diseases. Women who drink over 10 g and men who drink more than 20 g of pure alcohol daily are already consuming risky amounts. According to GEDA 2014/2015-EHIS data, 13.8% of women and 18.2% of men consume risky amounts of alcohol at least weekly. The consumption of potentially dangerous levels of alcohol is most widespread in the 45-64 age group. Across all age groups, the prevalence of risky alcohol consumption patterns is higher among highly educated women compared to women with a lower level of education. For men, this pattern only appears in those aged 65 and over. Preventive measures including social and environmental interventions and responsible drinking campaigns should contribute to further reducing risky alcohol consumption among the population.

Smoking poses a considerable health risk and is the leading cause of premature death. Germany has implemented numerous measures (such as tax increases, protection of non-smokers, and cigarette warning labels) to reduce the population’s tobacco consumption. According to the GEDA 2014/15–EHIS survey, 20.8% of women and 27.0% of men aged 18 and over smoke at least occasionally. For both genders, the share of smokers is highest among the younger age groups. Among women and men with higher levels of education, smoking is far less common than among those with lower levels of education. Since 2003, the share of smokers in the adult population has decreased. Compared to other European countries, and in spite of making considerable progress in tobacco prevention policy, Germany still has great potential for improvement in many areas, such as bans on tobacco adverts and tobacco taxation.

Abstract Background Children who are exposed to secondhand smoke (SHS) have an increased risk of a wide range of health problems and illnesses. Smoke-free legislation aims to improve indoor air quality and in this way protect the health of people who do not smoke. This paper examines trends in SHS exposure at home among children in Germany since the introduction of smoking bans in public places. Special focus is placed on the importance of the family of origin’s socioeconomic status (SES) and on parental smoking behaviour. Methods The analyses are based on two waves of the “German Health Interview and Examination Survey for Children and Adolescents” (KiGGS)—one of which was conducted immediately before the introduction of central smoke-free legislation in the 2003-2006 period, the other approximately 6 years later from 2009 to 2012. A comparison is made between the answers given by the parents of children aged between 0 to 6 (KiGGS baseline study, n = 6680; KiGGS Wave 1, n = 4455). Domestic SHS exposure is covered in the parent interviews by asking whether anyone is allowed to smoke at home in the presence of their child. Parental smoking behaviour is determined separately for mothers and fathers. SES is determined on the basis of the parents’ education, occupational status and income. Results The percentage of 0- to 6-year-old children exposed to SHS in the parental home fell from 23.9 to 6.6 % in the period from 2003-2006 to 2009-2012. At the same time, the percentage of children with at least one parent who smokes decreased from 49.8 to 41.8 %. While relative social inequalities in parental smoking behaviour have tended to increase over time, inequalities in domestic SHS exposure have persisted. Children whose parents smoke and children from low-SES families are still most likely to be exposed to tobacco smoke. In both study periods and after statistical adjustment for parental smoking behaviour, children with a low SES had a 6.6-fold higher risk for SHS exposure in the parental home than children from high-SES households. Conclusions The results of the KiGGS study show that the proportion of children in Germany who are exposed to SHS at home has declined significantly over the last few years. There is much to suggest that the smoke-free legislation that has been introduced in Germany has led to a heightened awareness of the health risks of SHS both in public and in the private sphere, as well as to a denormalization of smoking. Children whose parents smoke, and among them particularly children from socially disadvantaged families, should be recognised as key target groups when implementing future tobacco-control measures.

Background In most developed countries today the prevalence of smoking is higher among men and women with lower education levels. Furthermore, educational differences in smoking have increased over the last decades. As smoking prevalence is influenced by both smoking initiation and quitting, we analyzed the extent of educational inequalities in smoking uptake and cessation for different birth cohorts in Germany. Methods The analyses were based on pooled data of three waves (2009, 2010, 2012) of the nationwide telephone health survey “German Health Update” (GEDA) (n=62,606 aged 18 years and older). Seven 10-year birth cohorts (1920s-1980s) were included (n=59,757). Smoking behaviour was assessed by several questions on current and previous smoking status. Educational status was assessed by the highest school-leaving certificate and classified as low, middle, and high. Results For men and women born since the 1950s, the share of ever smokers was higher among those with lower education levels. The educational gradient in smoking initiation increased in younger cohorts among both sexes. In the 1980-89 birth cohort the share of ever smokers was about 30 percentage points higher in lower than in higher educated men (78.8% vs. 47.6%) and women (74.9% vs. 44.9%). Quitting rates, however, were higher among the higher educated compared with the less educated, especially in women born in the 1960s (54.8% vs. 30.6%) and 1970s (48.9% vs. 23.3%). Conclusions Particularly in the younger birth cohorts, lower educated men and women were more likely to start smoking and less likely to quit than higher educated men and women. When implementing tobacco prevention and cessation initiatives, efforts to reach also the lower educated population groups are necessary. If educational inequalities in smoking are not reduced, educational inequalities in tobacco-related morbidity and mortality are likely to increase in the future.