Stagnation and inequality: A pan-European analysis of structural determinants in smoking prevalence (2014-2019)

Background/Aim: Although the global prevalence of smoking has been steadily declining, aggregate trends conceal substantial regional differences across Europe, as well as socioeconomic and education-level inequalities. The aim of this study was to assess the widening regional and educational inequalities in smoking prevalence in Europe and de-lineate structural barriers to tobacco control against the backdrop of aggregate trends. Methods: Using European Statistical Office (Eurostat) data from 32 countries (2014–2019), daily smoking rates, indoor environmental tobacco smoke exposure, and smoking intensity were analyzed. To account for demographic differences, European averages were calculated using population-weighted means. Pearson correlations and multivariate regression models were utilized to examine country-level associations between educational attainment indices and smoking outcomes. Results: While the weighted European Union (EU) average for daily smoking declined slightly, regional divergence intensified. Nordic countries maintained the lowest prevalence (~12%), whereas Eastern European nations and Türkiye (~27–29%) exhibited stagnation or increases. A strong country-level educational gradient persisted; nations with higher tertiary attainment rates exhibited significantly lower aggregate smoking prevalence. Marked cross-country differences in indoor secondhand smoke exposure were observed; daily indoor tobacco smoke exposure exceeded 19% in countries such as Greece and Croatia but remained below 3% in Finland. Conclusion: The decline in smoking has stalled in structurally disadvantaged regions, supporting the “hardening hypothesis” (the phenomenon where the remaining smoker population becomes more resistant to quitting) at the macro level. Generic tobacco control measures are losing efficacy. To bridge the widening health equity gap, future interventions must target high levels of heavy smoking and the enforcement of smoke-free environments in lagging regions.