Smoking accounts for up to 60% of the gender gap in death rates across Europe, and kills twice as many men as alcohol, reveals research published online in Tobacco Control.
The reasons why women have been outliving men in developed European countries since the mid to late 18th century, in some cases, have been hotly contested.
The gender gap in death rates has sometimes been put down to simple biology, or the fact that women seek out health care more readily than men. But the magnitude and variability of the trends suggests a rather more complex picture, say the authors, who set out to explore this discrepancy in more detail.
They used World Health Organisation figures on death rates among men and women from all causes as well as those attributable to smoking and drinking in 30 European countries for the years closest to 2005.
Smoking related deaths included respiratory tract cancers, coronary artery disease, stroke and chronic obstructive pulmonary disease (COPD). Those related to alcohol included cancers of the throat and gullet and chronic liver disease as well as alcoholic psychosis and violence.
The 30 countries included Iceland, Greece, Malta, Cyprus, and several in Western and Eastern Europe, excluding the Russian Federation, and Scandinavia.
The proportion of the discrepancy in death rates for men and women attributable to smoking and alcohol was then calculated for all 30 countries by dividing the gender gap for each cause by the gender gap for all causes.
Deaths from all causes were higher for men than for women, the figures showed, but the excess in male deaths varied considerably across the countries studied, ranging from 188 per 100,000 of the population a year in Iceland to 942 per 100,000 in Ukraine.
Most countries with a gender gap of more than 400 per 100,000 were in Eastern Europe, but elsewhere Belgium, Spain, France, Finland and Portugal had the widest gaps.
There was an eightfold difference between the country with the lowest male death rate attributable to alcohol -- Iceland at 29 per 100,000 -- and that with the highest -- Lithuania at 253 per 100,000.
Deaths related to alcohol were particularly high among men in Eastern European countries, but they were also much higher for women there. Overall, the proportion of deaths attributable to alcohol ranged from 20% to 30%.
But despite large gender differences in alcohol consumption across Europe and the huge variation in alcohol related deaths, these were significantly lower than deaths caused by smoking.
There was a fivefold difference between countries with the lowest male death rates (Iceland at 97 per 100,000) attributable to smoking and those with the highest (Ukraine at 495 per 100,000).
But smoking was behind 40% to 60% of the gender gap in all countries, except Denmark, Portugal and France, where it was lower, and Malta where it was much higher (74%).
"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 the coming decades," say the authors.
"However, the extent to which this is realised will depend on the ways in which other health risk behaviours are patterned by gender," they add, pointing to the continuing uptake of smoking among young people and increases in harmful drinking.
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