## 3 Results  
In the last year of the time series (2021), the ASMR_50+ due to TBLC per 100,000 inhabitants observed in mainland Portugal was 158.0 and 40.4 among men and women, respectively. These AMSR_50+ for 2021 presented a large variation across the areas stratified by the level of urbanization, such that higher values were observed in the urban areas (183.0 in men and 45.9 in women) while the rural areas showed lower values (131.8 and 27.9 among men and women, respectively).  
Overall, the ASMR_50+ decreased among men but increased among women; however, the time trend was different between the geographic regions, as shown in Figures 1-3.  
In the rural areas (Figure 1), there were no significant variations in AMSR_50+ among the women, regardless of the geographic region. Among men living in the rural areas, there was an upward trend in AMSR_50+ observed in Centro, between 2011 and 2019 (APC = 4.11%; 95%CI from 1.35 to 6.94), that reverted thereafter, while no significant variation in rates was observed in Norte and in Alentejo.  
In the suburban areas (Figure 2), there was a significant increase in ASMR_50+ among women living in Norte (APC = 3.60%; 95% from 1.10 to 6.17) and in Centro (APC = 2.32%; 95% from 0.34 to 4.34), while no variation was observed among men living in the same regions. In Algarve, however, there was a significant decrease in AMSR_50+ among men from 2016 onwards (APC = \(-\)6.46%; 95%CI from \(-\)10.37 to \(-\)2.39), but there was no significant variation in AMSR_50+ among women.  
In the urban areas (Figure 3), there was no significant variation in AMSR-50+ among men and women living in Norte. The AMSR_50+ observed in Lisboa, however, showed a significant increase in women over the whole study period (APC = 3.21%; 95% CI from 1.54 to 4.91) and a significant decrease in among men from 2013 onwards (APC = \(-\)1.65; 95% CI from \(-\)2.40 to \(-\)0.90).  
Differences between geographic regions and level of urbanization were assessed through SMRs and the respective 95% CI. The results are shown separately for men (Figure 4) and women (Figure 5). The observed deaths were significantly higher than the expected for men living in Urban Norte (SMR = 125% 95% CI from 121 to 128), Urban Lisboa (SMR = 118% 95% CI from 115 to 122) and Suburban Algarve (SMR = 109% 95% CI from 102 to 117). The men living in Rural Norte (SMR = 72% 95% CI from 66 to 78), Rural Centro (SMR = 85% 95% CI from 78 to 92), and Suburban Centro (SMR = 78 95% CI from 75 to 81), however, presented a lower rate of mortality than expected (Figure 4).  
Figure 1. Time trends in ASMR_50+ observed in rural regions, stratified by gender ((A) among men and (B) among women). Graphics display modeled values for ASMR-50+.  
Figure 2: Time trends in ASME,50+ observed in suburban regions, stratified by gender (**A**) among men and (**B**) among women. Graphics display modeled values for ASME-50+.  
Figure 3: Time trends in ASMR,50+ observed in urban regions, stratified by gender (**(A)** among men and **(B)** among women). Graphics display modeled values for ASMR,50+.  
Figure 4: Standardized mortality ratio and respective 95% CI by region and level of urbanization among men. Red line means no differences between observed and expected values.  
Figure 5: Standardized mortality ratio and respective 95% CI by region and level of urbanization among women. Red line means no differences between observed and expected values.  
Among women, only those living in Urban Lisboa presented significantly higher deaths than expected (SMR = 125% 95% CI from 119 to 131). The observed deaths were significantly lower than expected for women living in all rural regions.