The German East-West Mortality Difference: Two Crossovers Driven by Smoking

Survival assessment and pre-diagnostic risk factors for lung cancer incidence: Insights from the Golestan Cohort Study

BACKGROUND

Lung cancer remains a pressing health issue globally. This study investigates survival rates and the impact of pre-diagnostic factors on lung cancer incidence in Golestan Cohort Study (GCS).

METHOD

The GCS, initiated in 2004 with enrollment concluding in 2008, comprises 49,783 individuals aged 40-75 from the Golestan province in northeastern Iran. Our analysis included all cases of lung, tracheal, and bronchial cancers diagnosed under ICD-10 codes C33-C34 from the study's inception to 2022, tracking participants until death. A sensitivity analysis, excluding lung cancer cases diagnosed within the initial 24 months of follow-up, was performed to address the reverse causation bias from previously undiagnosed conditions at baseline.

RESULTS

Out of 49,783 participants in the study, 132 were diagnosed with lung cancer, of whom 130 died by the end of the study. The age and sex-standardized incidence rate stood at 20.39 per 100,000 person-years. The median survival post-diagnosis was approximately four months, with one-year and five-year survival rates at 18.67% and 1.56%, respectively. Sensitivity analyses identified advanced age, male sex, opiate use history, pack-years of cigarette smoking, and the utilization of non-gaseous energy sources as lung cancer risk factors. In contrast, high physical activity and a BMI of 25 or higher were inversely associated with lung cancer risk.

CONCLUSION

Our study highlights the critical burden and low survival rates of lung cancer in resource-limited regions. Mitigating key risk factors and enhancing access to diagnostic and treatment services through targeted public health policies and comprehensive strategies are essential for ensuring equitable healthcare and improving lung cancer outcomes for underserved populations.

[Mortality trends in Germany in an international context]

BACKGROUND AND AIM

Due to its strong economy and a well-developed healthcare system, Germany is well positioned to achieve above-average reductions in mortality. Nevertheless, in terms of life expectancy, Germany is increasingly falling behind Western Europe. We compare mortality trends in Germany with other Western European countries, covering the period from 1960 to 2019. The focus is on long-term trends in Germany's ranking in international mortality trends. In addition, we conduct a detailed mortality analysis by age.

METHODS

Our analysis is mostly based on mortality data from the Human Mortality Database (HMD). Cause-specific mortality data originate from the database of the World Health Organization (WHO). For the international comparison of mortality trends, we use conventional mortality indicators (age-standardized mortality rate, period life expectancy).

RESULTS

Compared to other Western European countries, Germany has higher mortality in the middle and older age groups. Germany's life expectancy gap compared to Western Europe has grown during the past 20 years. In 2000, Germany was 0.73 years behind for men and 0.74 years behind for women. By 2019, these figures had risen to 1.43 and 1.34 years, respectively. This is mainly due to mortality from non-communicable diseases.

CONCLUSION

For Germany to catch up with other Western European countries, a stronger focus on further reducing mortality at ages 50+ is crucial. This also requires further research to understand the factors behind Germany's disadvantageous position.

Age-specific and cause-specific mortality contributions to the socioeconomic gap in life expectancy in Germany, 2003-21: an ecological study

BACKGROUND

Earlier death among people in socioeconomically deprived circumstances has been found internationally and for various causes of death, resulting in a considerable life-expectancy gap between socioeconomic groups. We examined how age-specific and cause-specific mortality contributions to the socioeconomic gap in life expectancy have changed at the area level in Germany over time.

METHODS

In this ecological study, official German population and cause-of-death statistics provided by the Federal Statistical Office of Germany for the period Jan 1, 2003, to Dec 31, 2021, were linked to district-level data of the German Index of Socioeconomic Deprivation. Life-table and decomposition methods were applied to calculate life expectancy by area-level deprivation quintile and decompose the life-expectancy gap between the most and least deprived quintiles into age-specific and cause-specific mortality contributions.

FINDINGS

Over the study period, population numbers varied between 80 million and 83 million people per year, with the number of deaths ranging from 818 000 to 1 024 000, covering the entire German population. Between Jan 1, 2003, and Dec 31, 2019, the gap in life expectancy between the most and least deprived quintiles of districts increased by 0·7 years among females (from 1·1 to 1·8 years) and by 0·1 years among males (from 3·0 to 3·1 years). Thereafter, during the COVID-19 pandemic, the gap increased more rapidly to 2·2 years in females and 3·5 years in males in 2021. Between 2003 and 2021, the causes of death that contributed the most to the life-expectancy gap were cardiovascular diseases and cancer, with declining contributions of cardiovascular disease deaths among those aged 70 years and older and increasing contributions of cancer deaths among those aged 40-74 years over this period. COVID-19 mortality among individuals aged 45 years and older was the strongest contributor to the increase in life-expectancy gap after 2019.

INTERPRETATION

To reduce the socioeconomic gap in life expectancy, effective efforts are needed to prevent early deaths from cardiovascular disease and cancer in socioeconomically deprived populations, with cancer prevention and control becoming an increasingly important field of action in this respect.

FUNDING

German Cancer Aid and European Research Council.

Forecasting the mortality burden of coronary heart disease and stroke in Germany: National trends and regional inequalities

BACKGROUND

The decline of cardiovascular disease (CVD) mortality has slowed in many countries, including Germany. We examined the implications of this trend for future coronary heart disease (CHD) and stroke mortality in Germany considering persistent mortality inequalities between former East and West Germany.

METHODS

We retrieved demographic and mortality data from 1991 to 2019 from the German Federal Statistical Office. Using a Bayesian age-period-cohort framework, we projected CHD and stroke mortality from 2019 to 2035, stratified by sex and German region. We decomposed annual changes in deaths into three components (mortality rates, population age structure and population size) and assessed regional inequalities with age-sex-standardized mortality ratios.

RESULTS

We confirmed that declines of CVD mortality rates in Germany will likely stagnate. From 2019 to 2035, we projected fewer annual CHD deaths (114,600 to 103,500 [95%-credible interval: 81,700; 134,000]) and an increase in stroke deaths (51,300 to 53,700 [41,400; 72,000]). Decomposing past and projected mortality, we showed that population ageing was and is offset by declining mortality rates. This likely reverses after 2030 leading to increased CVD deaths thereafter. Inequalities between East and West declined substantially since 1991 and are projected to stabilize for CHD but narrow for stroke.

CONCLUSIONS

CVD deaths in Germany likely keep declining until 2030, but may increase thereafter due to population ageing if the reduction in mortality rates slows further. East-West mortality inequalities for CHD remain stable but may converge for stroke. Underlying risk factor trends need to be monitored and addressed by public health policy.

The Dangers of Drawing Cohort Profiles From Period Data: A Research Note

Drawing cohort profiles and cohort forecasts from grids of age-period data is common practice in demography. In this research note, we (1) show how demographic measures artificially fluctuate when calculated from the diagonals of age-period rates because of timing and cohort-size bias, (2) estimate the magnitude of these biases, and (3) illustrate how prediction intervals for cohort indicators of mortality may become implausible when drawn from Lee-Carter methods and age-period grids. These biases are surprisingly large, even when the cohort profiles are created from single-age, single-year period data. The danger is that we overinterpret deviations from expected trends that were induced by our own data manipulation.

The underwhelming German life expectancy

This article contributes to the discussion on the determinants of diverging life expectancy in high-income countries, with a focus on Germany. To date, much of this discourse has centered around the social determinants of health, issues of healthcare equity, poverty and income inequality, and new epidemics of opioids and violence. Yet despite doing well on all of these metrics and having numerous advantages such as comparatively strong economic performance, generous social security, and an equitable and well-resourced health care system, Germany has been a long-time life expectancy laggard among the high-income countries. Using aggregated population-level mortality data for Germany and selected six high-income countries (Switzerland, France, Japan, Spain, the United Kingdom, and the United States) from the Human Mortality Database and WHO Mortality Database, we find that the German longevity shortfall is mainly explained by a longstanding disadvantage in survival among older adults and adults nearing statutory retirement age, which mainly stems from sustained excess cardiovascular disease mortality, even when compared to other laggard countries such as the US and the UK. Patchy contextual data suggests that the unfavorable pattern of cardiovascular mortality may be driven by underperforming primary care and disease prevention. More systematic and representative data on risk factors are needed to strengthen the evidence base on the determinants of the controversial and long-standing health gap between more successful countries and Germany. The German example calls for broader narratives of population health that embed the variety of epidemiological challenges populations face around the globe.

Different health systems - Different mortality outcomes? Regional disparities in avoidable mortality across German-speaking Europe, 1992-2019

BACKGROUND

Evaluating the impact of health systems on premature mortality across different countries is a very challenging task, as it is hardly possible to disentangle it from the influence of contextual factors such as cultural differences. In this respect, the German-speaking area in Central Europe (Austria, Germany, South Tyrol and large parts of Switzerland) represents a unique 'natural experiment' setting: While being exposed to different health policies, they share a similar culture and language.

METHODS

To assess the impact of different health systems on mortality differentials across the German-speaking area, we relied on the concept of avoidable mortality. Based on official mortality statistics, we aggregated causes of death below age 75 that are either 1) amenable to health care or 2) avoidable through primary prevention. We calculated standardised death rates and constructed cause-deleted life tables for 9 Austrian, 96 German, 1 Italian and 5 Swiss regions from 1992 to 2019, harmonised according to the current territorial borders.

RESULTS

There are strong north-south and east-west gradients in amenable and preventable mortality across the studied regions to the advantage of the southwest. However, the Swiss regions still show significantly lower mortality levels than the neighbouring regions in southern Germany. Eliminating avoidable deaths from the life tables reduces spatial inequality in life expectancy in 2017/2019 by 30% for men and 28% for women.

CONCLUSIONS

The efficiency of health policies in assuring timely and adequate health care and in preventing risk-relevant behaviour has room for improvement in all German regions, especially in the north, west and east, and in eastern Austria as well.

Quantifying the contribution of smoking to regional mortality disparities in Germany: a cross-sectional study

OBJECTIVES

Substantial regional variation in smoking behaviour in Germany has been well documented. However, little is known about how these regional differences in smoking affect regional mortality disparities. We aim to assess the contribution of smoking to regional mortality differentials in Germany over the last four decades.

DESIGN

A cross-sectional study using official cause-specific mortality data by German Federal State aggregated into five macro-regions: East, North, South, West-I and West-II.

PARTICIPANTS

The entire population of Germany stratified by sex, age and region during 1980-2019.

MAIN OUTCOME MEASURES

Smoking-attributable fraction estimated using the Preston-Glei-Wilmoth method; life expectancy at birth before and after the elimination of smoking-attributable deaths.

RESULTS

In all macro-regions, the burden of past smoking has been declining among men but growing rapidly among women. The hypothetical removal of smoking-attributable deaths would eliminate roughly half of the contemporary advantage in life expectancy of the vanguard region South over the other macro-regions, apart from the East. In the latter, smoking only explains around a quarter (0.5 years) of the 2-year difference in male life expectancy compared with the South observed in 2019. Among women, eliminating smoking-attributable deaths would put the East in a more disadvantageous position compared with the South as well as the other macro-regions.

CONCLUSION

While regional differences in smoking histories explain large parts of the regional disparities in male mortality, they are playing an increasingly important role for female mortality trends and differentials. Health policies aiming at reducing regional inequalities should account for regional differences in past smoking behaviour.

Dietary Choices Impact on Greenhouse Gas Emissions: Determinants and Correlates in a Sample of Adults from Eastern Germany

The present study estimated diet-related greenhouse gas emissions (GHGE) and land use (LU) in a sample of adults, examined main dietary contributors of GHGE, and evaluated socio demographic, lifestyle, and wellbeing factors as potential determinants of high environmental impact. A cross-sectional design based on data collected from the European Prospective Investigation into Cancer and Nutrition (EPIC)—Potsdam cohort (2010–2012) was used. Usual diet was assessed using food frequency questionnaires. Diet-related GHGE and LU were calculated using a European-average lifecycle analyses-food-item database (SHARP-ID). Information on potential determinants were collected using self-administered questionnaires. Men (n = 404) and women (n = 401) at an average age of 66.0 ± 8.4 years were included. Dietary-related energy-adjusted GHGE in men was 6.6 ± 0.9 and in women was 7.0 ± 1.1 kg CO2 eq per 2000 kcal. LU in men was 7.8 ± 1.2 and in women was 7.7 ± 1.2 m2/year per 2000 kcal. Food groups contributing to most GHGE included dairy, meat and non-alcoholic beverages. Among women, being single, having a job, being a smoker and having higher BMI were characteristics associated with higher GHGE, whereas for men these included being married, longer sleeping duration and higher BMI. Further studies are warranted to provide insights into population-specific determinants of sustainable dietary choices.

The progression of the tobacco epidemic in India on the national and regional level, 1998-2016

BACKGROUND

Evidence regarding the progression of the tobacco epidemic remains fragmented in low- and middle-income countries. In India, most of the studies that examined tobacco consumption focused on one time point, on the country as a whole, and on men. Despite important gender differences in tobacco consumption, vast economic and cultural differences exist within India. We, therefore, assessed the progression of the tobacco epidemic in India on both the national and the regional level, by gender.

METHODS

We use information on current tobacco use among Indians aged 15-49 from three rounds of the National Family Health Survey (NFHS) (1998-99, 2005-06, 2015-16) to estimate the age-standardized sex specific smoking and smokeless tobacco prevalence across India and its states.

RESULTS

Age-standardized tobacco use prevalence in India increased between 1998-1999 and 2005-2006, and declined from 2005-2006 to 2015-2016, simultaneously for men and women. There are substantial spatial differences in the progression of the tobacco epidemic in India. While tobacco use declined in the majority of states, we observe high and increasing use for men in the north-eastern states of Manipur, Mizoram and Nagaland, and for women in the western state of Gujarat and north-eastern state of Manipur. We observed even more states with a recent increasing prevalence in either tobacco smoking or smokeless tobacco. Throughout, prevalence of tobacco use has been higher among men than women for all Indian regions, and remained higher than the national average in the north-eastern states.

CONCLUSIONS

Our results suggest that India and the majority of its states experienced a 'compressed tobacco epidemic' in which the prevalence of tobacco consumption increased and decreased simultaneously for women and men over a comparatively short period of time. Despite the overall progress India made in reducing tobacco use, further lowering tobacco consumption remains a public health priority, as the prevalence of smoking and/or smokeless tobacco use remains high in a number of states. We therefore conclude that tobacco regulations should be expanded with the aim of reducing the overall health burden associated with tobacco consumption across India.

Gender and regional pattern of alcohol use and projection of problematic drinking in India, 1998-2016

PURPOSE OF THE STUDY

Alcohol use is the third leading risk factor for premature mortality. India is one of the largest markets for alcoholic beverages. Existing research in India is localized to specific settings lacking national generalizability. The present study aims to estimate the trends in alcohol use in India by gender and regions and to estimate the current projected number of the population involved in problematic drinking.

METHODS

The National Family Health Survey (NFHS) is used to estimate the age-standardized alcohol prevalence by gender and region. World Bank, 2019 population estimates are used to estimate the total population currently involved in problematic drinking, using the recent alcohol prevalence estimates.

FINDINGS

Nationally, the age-standardized prevalence of alcohol use increased between 1998-1999 and 2005-2006 and declined thereafter, being higher among men than women. Exceptions to the declines after 2005 are seen in some regions where alcohol use still increased. A 43.6% increase and 8.5% decrease in the age-standardized prevalence of problematic drinking is observed among men and women, respectively, between 2005-2006 and 2015-2016. However, problematic drinking increased in some regions for both men and women. 103.62 million men and 3.34 million women in India were involved in problematic drinking during 2019, with the highest incidences being among men aged 40-44 years and among women aged 45-49 years.

CONCLUSION

Despite the overall progress India has made in reducing its alcohol prevalence, lowering it further remains a public health priority. There was a substantial rise in the prevalence of problematic drinking among the population, which warrants immediate action. Spreading knowledge and awareness about the negative health effects of problematic drinking among the adult population seems necessary. Strict implementation of policies would therefore not only aid in reducing the prevalence of alcohol use and problematic drinking, but, in turn, would also help to reduce the burden of alcohol-related morbidity and associated mortality in India.

Declining regional disparities in mortality in the context of persisting large inequalities in economic conditions: the case of Germany

BACKGROUND

Subnational regional mortality inequalities are large and appear to be mostly increasing within industrialized countries, although comparative studies across high-income countries are scarce. Germany is an important country to examine because it continues to experience considerable economic disparities between its federal states, in part resulting from its former division.

METHODS

We analyse state-level mortality in Germany utilizing data from a newly constructed regional database based on the methodology of the Human Mortality Database. We compare time trends (1991-2015) in the German state-level standard deviation in life expectancy to that of other large, wealthy countries and examine the association between mortality and economic inequalities at the regional level. Finally, using contour-decomposition methods, we investigate the degree to which age patterns of mortality are converging across German federal states.

RESULTS

Regional inequalities in life expectancy in Germany are comparatively low internationally, particularly among women, despite high state-level inequalities in economic conditions. These low regional mortality inequalities emerged 5-10 years after reunification. Mortality is converging over most ages between the longest- and shortest-living German state populations and across the former East-West political border, with the exception of an emerging East-West divergence in mortality among working-aged men.

CONCLUSIONS

The German example shows that large regional economic inequalities are not necessarily paralleled with large regional mortality disparities. Future research should investigate the factors that fostered the emergence of this unusual pattern in Germany.

[30 years of German unification: achievements and remaining differences in mortality trends by age and cause of death]

BACKGROUND

During the German division, two culturally very similar populations were exposed to very disparate socioeconomic conditions, which converged again after 1989. The impact of healthcare and life circumstances on mortality differences can better be estimated when cultural explanations are widely neglectable.

OBJECTIVES

For the first time, we analyse harmonised cause-of-death data explicitly by age. Hereby, we can show which ages or birth cohorts were particularly affected by German division and reunification in their mortality and to which causes of death this is attributable.

MATERIALS AND METHODS

We harmonised the German cause-of-death statistics by applying an internationally standardised harmonisation process to account for differences and breaks in cause-of-death coding practices. We analysed the data using decomposition methods.

RESULTS

During the 1980s, east-west disparities were increasing as progress in the reduction of cardiovascular mortality was much stronger in West Germany, notably at older ages. After 1989, East Germany was able to catch up to the west in many areas. This is especially true for elderly persons and women, while east-west disparities are still visible today, particularly among male adult cohorts (1950-1970) strongly affected by the East German transition crisis.

CONCLUSIONS

The lower life expectancy of the East German population in the late 1980s was primarily caused by a slower pace of the cardiovascular revolution. The remaining present-day disparities are rather an aftermath of the East German transition crisis than direct aftereffects of the division.

Statistical projection methods for lung cancer incidence and mortality: a systematic review

OBJECTIVES

To identify and summarise all studies using statistical methods to project lung cancer incidence or mortality rates more than 5 years into the future.

STUDY TYPE

Systematic review.

METHODS

We performed a systematic literature search in multiple electronic databases to identify studies published from 1 January 1988 to 14 August 2018, which used statistical methods to project lung cancer incidence and/or mortality rates. Reference lists of relevant articles were checked for additional potentially relevant articles. We developed an organisational framework to classify methods into groups according to the type of data and the statistical models used. Included studies were critically appraised using prespecified criteria.

RESULTS

One hundred and one studies met the inclusion criteria; six studies used more than one statistical method. The number of studies reporting statistical projections for lung cancer increased substantially over time. Eighty-eight studies used projection methods, which did not incorporate data on smoking in the population, and 16 studies used a method which did incorporate data on smoking. Age-period-cohort models (44 studies) were the most commonly used methods, followed by other generalised linear models (35 studies). The majority of models were developed using observed rates for more than 10 years and used data that were considered to be good quality. A quarter of studies provided comparisons of fitted and observed rates. While validation by withholding the most recent observed data from the model and then comparing the projected and observed rates for the most recent period provides important information on the model's performance, only 12 studies reported doing this.

CONCLUSION

This systematic review provides an up-to-date summary of the statistical methods used in published lung cancer incidence or mortality projections. The assessment of the strengths of existing methods will help researchers to better apply and develop statistical methods for projecting lung cancer rates. Some of the common methods described in this review can be applied to the projection of rates for other cancer types or other non-infectious diseases.

Avoidable Cancer Mortality in Germany Since Reunification: Regional Variation and Sex Differences

Background: Regional comparisons of cancer-related mortality in Germany are traditionally focused on disparities between East and West Germany. Recent improvements in all-cause and cancer-related mortality show a diverse regional pattern beyond the known East-West mortality divide. A generalized approach of the avoidable/amenable cancer mortality definition is applied for suitable regional comparisons of long-term trends. Methods: Standardized death rates of preventable and amenable cancer mortality for men and women were computed for the period 1990-2014 to observe sex-specific excess mortality due to specific cancers after the German reunification. For regional comparison, three German super regions were defined in Eastern, Northwestern, and Southwestern Germany to account for similarities in long-term regional premature and cancer-related mortality patterns, socioeconomic characteristics, and age structure. Results: Since preventable and amenable cancer mortality rates typically have driven the recent trends in premature mortality, our findings underline the current regional pattern of preventable cancer mortality for males with disadvantages for Eastern Germany, and advantages for Southwestern Germany. Among women, the preventable cancer mortality has increased in Northwestern and Southwestern Germany after the German reunification but has decreased in Eastern Germany and converged to the pattern of Southwestern Germany. Similar patterns can be observed for females in amenable cancer mortality. Conclusions: Although the "traditional" East-West gap in preventable cancer mortality was still evident in males, our study provides some hints for more regional diversity in avoidable cancer mortality in women. An establishing north-south divide in avoidable cancer mortality could alter the future trends in regional cancer-related mortality in Germany.

Avoidable Mortality in the German Baltic Sea Region Since Reunification: Convergence or Persistent Disparities?

The consequences of political reunification for health and mortality have the unique character of a 'natural experiment'. This is particularly true for the formerly divided German Baltic Sea region due to its cultural and geographic commonalities. This paper ascertains the changes and differences in premature mortality at ages 0-74 in urban and rural areas of the German states of Mecklenburg-Vorpommern (MV) and Schleswig-Holstein (SH) since reunification and the contribution made by 'avoidable' mortality. Using official cause-of-death data, the effectiveness of health care and health policies was measured based on the concept of avoidable mortality in terms of both amenable and preventable conditions. Methods of decomposition and standardisation were employed in order to erase the compositional effect from the mortality trend. As a result, mortality differences relate primarily to men and the rural areas of the German Baltic Sea region. Whereas the mortality levels in the urban areas of MV and SH have converged, the rural areas of MV still show higher levels of preventable and amenable mortality. The results show that the accessibility and quality of medical care in the thinly populated areas of MV and the effectiveness of inter-sectoral health policies through primary prevention, particularly with regard to men, have room for improvement.

Socioeconomic disparities in life expectancy gains among retired German men, 1997-2016

Background

Although estimates of socioeconomic mortality disparities in Germany exist, the trends in these disparities since the 1990s are still unknown. This study examines mortality trends across socioeconomic groups since the late 1990s among retired German men aged 65 and above.

Methods

Large administrative data sets were used to estimate mortality among retired German men, grouped according to their working-life biographies. The data covered the years 1997–2016 and included more than 84.1 million person-years and 4.3 million deaths. Individual pension entitlements served as a measure of lifetime income. Changes in total life expectancy at age 65 over time were decomposed into effects of group-specific mortality improvements and effects of compositional change.

Results

Over the two decades studied, male mortality declined in all income groups in both German regions. As mortality improved more rapidly among higher status groups, the social gradient in mortality widened. Since 1997, the distribution of pension entitlements of retired East German men has shifted substantially downwards. As a result, the impact of the most disadvantaged group on total mortality has increased and has partly attenuated the overall improvement.

Conclusion

Our results demonstrate that socioeconomic deprivation has substantial effects on levels of mortality in postreunification Germany. While East German retirees initially profited from the transition to the West German pension system, subsequent cohorts had to face challenges associated with the transition to the market economy. The results suggest that postreunification unemployment and status decline had delayed effects on old-age mortality in East Germany.

Developments in life expectancy in Germany. Current trends

Since the beginning of the 1990s, life expectancy in Germany has increased by 4.2 years among women (to 83.2 years), and by 5.9 years among men (to 78.4 years). This rise is related to the increasing convergence of life expectancy in Germany's new and old federal states. Recently, life expectancy among women in the new federal states has even risen slightly above the level found in the old federal states. In addition, differences between socioeconomic groups continue to be observed in Germany. Women in the highest income group have a 4.4-year longer life expectancy than women in the lowest income group. Similarly, an 8.6-year difference exists between men in the highest income group and men in the lowest income group. Influenza waves can adversely affect the development of life expectancy in certain calendar years. In comparison to other European countries, Germany has a mid-range life expectancy: the current difference between life expectancy in Germany and Switzerland (the European country with the highest life expectancy) is 2.7 years.