Study protocol of the German Study on Tobacco Use (DEBRA): a national household survey of smoking behaviour and cessation

Smokers' perception of the comparative health risks of cigarettes, e-cigarettes and heated tobacco products: a survey among the German population

BACKGROUND

Tobacco cigarettes, e-cigarettes and heated tobacco products can pose different health risks (harm continuum). As current tobacco smokers could benefit from switching to less harmful products, we aimed to assess current smokers' perceived comparative health risks of these three products and to explore associations between risk perceptions and specific user characteristics.

METHODS

We analysed data from 11 waves (2019-2021; N = 5657 current tobacco smokers) of a representative, cross-sectional household survey conducted in Germany. Associations were assessed with multivariable logistic regression models.

RESULTS

55.2% of smokers (95%CI = 53.8-56.5%) ranked cigarettes as the most harmful product. 36.1% of smokers (95%CI = 34.8-37.3%) perceived e-cigarettes and 33.8% (95%CI = 32.5-35.0%) heated tobacco products as more harmful than cigarettes. Misperceptions that e-cigarettes or heated tobacco products are more harmful to health than cigarettes increased over the 3-year study period and were more common among those with lower educational attainment.

CONCLUSIONS

Only half of current tobacco smokers in Germany perceive the comparative health risks of cigarettes adequately and such misperceptions have increased recently. As current smokers could benefit most from switching to less harmful products, educational campaigns are needed to inform this group about the health risks of tobacco smoking and the comparative health risks of the various nicotine and tobacco products along the harm continuum.

[Smoke-free in Psychiatry - A Qualitative Analysis of Staff Perspectives]

BACKGROUND

People with mental illness are more likely to be nicotine-dependent and they have a shorter life expectancy as a result of smoking. Although guidelines recommend smoking cessation support, this is rarely provided by psychiatric staff who often view the implementation of smoke-free policies critically.

METHOD

We undertook inductive thematic analysis of the free-text fields of a staff survey on smoking.

RESULTS

Feedback on the topic was often emotional and related to the areas patient care, staff and the protection of non-smokers. Participants were often concerned that smoking cessation could worsen the patient's psychiatric condition or lead to aggressive behavior.

CONCLUSIONS

There is no scientific evidence for these concerns. It is important to counteract false assumptions by providing the appropriate training on smoking cessation.

Resting-state functional connectivity and structural differences between smokers and healthy non-smokers

Previous studies have shown an association between cigarette use and altered resting-state functional connectivity (rsFC) in many large-scale networks, sometimes complemented by measures of cortical atrophy. In this study, we aimed to further explore the neural differences between smokers and healthy non-smokers through the integration of functional and structural analyses. Imaging data of fifty-two smokers and forty-five non-smokers were analyzed through an independent component analysis for group differences in rsFC. Smokers showed lower rsFC within the dorsal attention network (DAN) in the left superior and middle frontal gyrus and left superior division of the lateral occipital cortex compared to non-smokers; moreover, cigarette use was found to be associated with reduced grey matter volume in the left superior and middle frontal gyrus and right orbitofrontal cortex, partly overlapping with functional findings. Within smokers, daily cigarette consumption was positively associated with increased rsFC within the cerebellar network and the default mode network and decreased rsFC within the visual network and the salience network, while carbon monoxide level showed a positive association with increased rsFC within the sensorimotor network. Our results suggest that smoking negatively impacts rsFC within the DAN and that changes within this network might serve as a circuit-based biomarker for structural deficits.

Associations between body mass index and smoking behaviour: A cross-sectional study of the German adult population

BACKGROUND

Both smoking and high body weight are risk factors for disease, hence, the association between smoking and body weight is an important health issue. Furthermore, concern about weight gain after quitting smoking is for many smokers a barrier to smoking cessation. The present study aims to explore the association between body mass index (BMI) and current tobacco smoking status in the population of Germany, and smoking and quitting behaviour amongst smokers (and recent ex-smokers =<12 months since quitting).

METHODS

Cross-sectional analysis of two waves of data collected from March through June 2021 through a representative face-to-face household survey in Germany (N = 3 997 respondents aged ≥18). The associations between smoking and quitting behaviours and BMI were analysed through four regression models adjusted for socio-demographic, socio-economic, and smoking characteristics of respondents.

RESULTS

Long-term ex-smokers (>= 12 months since quitting smoking) were more likely to have a higher BMI compared to never smokers (β = 0.64, 95% confidence interval (CI) = 0.10-1.19). There was no statistically significant association between current smoking status or recent ex-smoking status and BMI (β = -0.29,95 %CI = -0.75-0.17 and β = -0.53, 95 %CI = -2.45-1.40). Among current smokers, no statistically significant association was found between BMI and the motivation to stop smoking (OR = 1.01, 95 %CI = 0.99-1.03). Neither number of cigarettes smoked a day nor outcome of most recent quit attempt were related to BMI (β = 0.01, 95 %CI = -0.04-0.05 and OR = 0.41, 95 %CI = 0.05-3.05).

CONCLUSION

In the German population long-term ex-smoking but not current and recent ex-smoking was associated with increased BMI. Future research should further explore the association between smoking behaviour and abdominal obesity, preferably using a more accurate measure for abdominal obesity than BMI.

Cannabis Use in Germany

BACKGROUND

The federal government of Germany is planning to liberalize the recreational cannabis market for adults. We aimed to collect key baseline data on frequency of use, routes of administration, and co-use of cannabis and inhaled nicotine or tobacco products in the population.

METHODS

Based on data from a national survey of 9644 people aged >14 years, we analyzed self-reported use of cannabis in the past 12 months and preferred route of administration (single choice: smoked with tobacco; smoked without tobacco; inhaled without tobacco; consumed with food; consumed in another form).

RESULTS

The prevalence of past-year cannabis use was 4.6% (95% CI [4,2; 5,1%]), with higher rates among 14-24- (11.4%) and 25-39-year-olds (8.2%) as well as among co-users of inhaled nicotine or tobacco products, particularly waterpipe users (27.0%). Smoking cannabis with or without tobacco was the preferred route of administration, reported by 92.4% (95% CI [89,6; 94,6%]). It was most frequently reported by 14-24-year-olds and by co-users of inhaled nicotine or tobacco products.

CONCLUSION

Smoking remains the predominant form of using cannabis-especially among younger users, who are at greatest risk of cannabis-related consequences. The true prevalence of cannabis use may have been underestimated in our study, however, as not all participants answered the questions on cannabis. Nevertheless, preventive and harm reduction efforts are needed to reduce the harm from using cannabis. Continuous monitoring is required to evaluate the effects of the forthcoming law changes in Germany.

Are people interested in receiving advice from their general practitioner on how to protect their health during heatwaves? A survey of the German population

OBJECTIVE

Climate change increases the frequency, intensity and length of heatwaves, which puts a particular strain on the health of vulnerable population groups. General practitioners (GPs) could reach these people and provide advice on protective health behaviour against heat. Data is lacking on whether and what topic of GP advice people are interested in, and whether specific person characteristics are associated with such interests.

DESIGN

Cross-sectional, nationwide, face-to-face household survey, conducted during winter 2022/2023.

SETTING

Germany.

PARTICIPANTS

Population-based sample of 4212 respondents (aged 14-96 years), selected by using multistratified random sampling (50%) combined with multiquota sampling (50%).

MAIN OUTCOME MEASURE

Interest in receiving GP advice on health protection during heatwaves (yes/no), and the topic people find most important (advice on drinking behaviour, nutrition, cooling, cooling rooms, physical activity or medication management). Associations between predefined person characteristics and the likelihood of interest were estimated using adjusted logistic regressions.

RESULTS

A total of 4020 respondents had GP contact and provided data on the outcome measure. Of these, 23% (95% CI=22% to 25%) expressed interest in GP advice. The likelihood of expressing interest was positively associated with being female, older age (particularly those aged 75+ years: 38% were interested), having a lower level of educational attainment, having a migration background, living in a more urban area, and living in a single-person household. It was negatively associated with increasing income. Advice on medication management received highest interest (25%).

CONCLUSIONS

During winter season 2022/2023, around one quarter of the German population with GP contact-and around 40% of those aged 75+ years-was estimated to have a stated interest in receiving GP advice on protective health behaviour during heatwaves, especially on medication management. Climate change is creating new demands for healthcare provision in general practice. This study provides initial relevant information for research and practice aiming to address these demands.

Rauchen – Wissenswertes über Tabak und alternative Produkte

Tabakrauchen ist weltweit die häufigste vermeidbare Ursache für Krankheit und vorzeitigen Tod. Rauchen ist keine Life-Style-Entscheidung oder nur eine (schlechte) Angewohnheit. Es ist eine chronische Krankheit, die viele Erkrankungen mitverursacht und aggraviert. Durch das psychoaktive Nikotin ist Rauchen zusätzlich eine Suchterkrankung. Bei der Strategie zur Harm Reduction sollen Raucher die Tabakzigarette durch alternative nikotinhaltige Produkte („Alternative Nicotine Delivery Products“), wie die E-Zigarette oder Tabakerhitzer (Heat-not-burn-Produkte), ersetzen. Tabakkonzerne bewerben im Rahmen ihrer Marketingstrategie diese Produkte mit einer Schadstoffreduktion um 95%. Jedoch stehen unabhängige Forschungen und Langzeitergebnisse diesbezüglich aus. Raucher, die zu derartigen Produkten wechseln, sind durch die fortbestehende Nikotinabhängigkeit weiterhin langfristig den Belastungen durch (kardio)toxische und karzinogene Substanzen ausgesetzt. Die gesundheitlichen Auswirkungen dieser inhalativen Noxen werden dargestellt, wobei die Heat-not-burn-Produkte eine Mittelstellung zwischen der schädlichsten Tabakzigarette und den (möglicherweise) weniger gesundheitsschädlichen E-Zigaretten einnehmen. Das Fortbestehen einer (wenn auch reduzierten) kontinuierlichen Exposition in Verbindung mit einer Nikotinabhängigkeit ist keine Alternative zu einer professionellen evidenzbasierten multimodalen Tabakentwöhnung, die endlich flächendeckend (auch in Deutschland) angeboten werden muss. Ziel sollte der komplette Verzicht auf inhalative Noxen sein, ohne jegliche Toleranz für die Marketingstrategien der Tabakkonzerne.

Die Medienkampagne „Deine Chance“

Zusammenfassung: Zielsetzung: In 2021 wurde die bundesweite Medienkampagne „Deine Chance“ der damaligen Beauftragten der Bundesregierung für Sucht- und Drogenfragen und des Bundesministeriums für Gesundheit durchgeführt, um Raucherinnen und Raucher zu motivieren, mit dem Rauchen aufzuhören. Ziel unserer Studie war, die Wahrnehmung der Kampagne und ihre Effekte auf Rauchstoppmotivation und Rauchstoppversuche zu untersuchen. Methodik: Im Rahmen der repräsentativen Deutschen Befragung zum Rauchverhalten (DEBRA) wurden 1550 Raucher_innen im Zeitraum vor der Kampagne (18.02. bis 30.05.2021) und 2330 während der Kampagne (31.05. bis 14.11.2021) befragt. Spezifische Fragen bezogen sich auf die Wahrnehmung der Kampagne und davon ausgehende Impulse zur Änderung des Rauchverhaltens. Mögliche Effekte wurden anhand der Motivation zum Rauchstopp Skala sowie dem Anteil der Raucher_innen mit mindestens einem Rauchstoppversuch gemessen. Ergebnisse: 14.6 % (95%KI=13.2-16.1) der Raucher_innen nahm die Kampagne wahr. Hinsichtlich der Altersgruppen wurde die Kampagne am häufigsten von 14-24-Jährigen wahrgenommen (19.1 %, 95%KI=14.9-24.0). Raucher_innen mit niedriger Schulbildung nahmen die Kampagne seltener wahr als Raucher_innen mit hoher Schulbildung (OR=0.65, 95%KI=0.46-0.93). Unter den Raucher_innen, welche die Kampagne wahrgenommen hatten, informierten sich 6.4 % (95%KI=3.0-11.9) über die Kampagne, und 13.6 % (95%KI=9.1-19.0) wurden angeregt, über einen Rauchstopp nachzudenken. Im Vergleich zum Zeitraum vor der Kampagne gab es bei den Raucher_innen während der Kampagne keinen Unterschied in der Rauchstoppmotivation (OR=0.96, 95%KI=0.85-1.08) oder in durchgeführten Rauchstoppversuchen (OR=0.96, 95%KI=0.69-1.35). Schlussfolgerungen: Die Medienkampagne „Deine Chance“ hatte vermutlich keine nennenswerten Effekte auf die Rauchstoppmotivation und Rauchstoppversuche der Raucher_innen in Deutschland. Effektivere tabakkontrollpolitische Maßnahmen sind dringend notwendig, um das langfristige Ziel einer rauchfreien Gesellschaft zu erreichen.

Trends and consumption patterns in the use of e-cigarettes among adolescents and young adults in Germany (the DEBRA study)

INTRODUCTION

Considering the growing popularity and rapid evolution of e-cigarettes, we examined e-cigarette use and tobacco smoking trends, and e-cigarette consumption patterns (i.e., device type, nicotine level) among adolescents and young adults in Germany.

METHODS

Data from 26 waves of the German Study on Tobacco Use (DEBRA), a repeated cross-sectional nationwide household survey, were used to explore trends in the prevalence of ever e-cigarette use and tobacco smoking in a sample of adolescents (aged 14-17 years, N = 1,396) and young adults (aged 18-24 years, N = 4,685) between June/July 2016 and Aug/Sept 2020. Among current e-cigarette users (N = 208), consumption patterns were examined. Associations with e-cigarette use were analysed using multivariable regression.

RESULTS

Adolescent e-cigarette use increased from 9.2% in 2016 to 16.5% in 2017, decreased in 2018 to 8.3% and then gradually increased to 13.4% by 2020. Adolescent tobacco smoking followed a similar trend. Young adult e-cigarette use rates remained relatively stable at 19.1% on average, while tobacco smoking slowly declined (2016: 44.7%, 2020: 38.5%). More than half of current e-cigarette users used refillable-style e-cigarettes (59.4% adolescents; 68.4% young adults) and also smoked tobacco (62.5% adolescents; 79.4% young adults). About 41.6% of adolescents and 56.0% of young adults vaped with nicotine. Among young adults, men (OR = 1.5; 95%CI: 1.3-1.8) and former (OR = 9.6; 95%CI: 1.1-13.1) and current (OR = 10.7; 95%CI: 8.7-13.2) tobacco smokers were more likely to have vaped.

CONCLUSION

E-cigarette use continues to rise in German adolescents and young adults requiring targeted health interventions and campaigns aimed at preventing and/or reducing use in this population.

Prevalence and characteristics of hazardous and harmful drinkers receiving general practitioners' brief advice on and support with alcohol consumption in Germany: results of a population survey

OBJECTIVE

The German treatment guideline on alcohol-related disorders recommends that general practitioners (GPs) offer brief advice on, and support with, reducing alcohol consumption to hazardous (at risk for health events) and harmful (exhibit health events) drinking patients. We aimed to estimate the implementation of this recommendation using general population data.

DESIGN

Cross-sectional analysis of data (2021/2022) of a nationwide, population-based household survey.

SETTING

Germany.

PARTICIPANTS

Population-based sample of 2247 adult respondents who reported hazardous or harmful drinking according to the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C; score women: 4-12 and men: 5-12).

MAIN OUTCOME MEASURE

Ever receipt of 'brief GP advice on, or support with, reducing alcohol consumption'. Differences in the likelihood of ever receiving advice and/or support (yes/no) relative to respondents' sociodemographic, smoking and alcohol consumption characteristics were estimated using logistic regressions.

RESULTS

Ever receipt of GP advice on/support with reducing drinking was reported among 6.3% (95% CI=5.3% to 7.4%), and the offer of support among 1.5% (95% CI=1.1% to 2.1%) of the hazardous and harmful drinking respondents. The likelihood of having ever received advice/support was positively associated with being older (OR=1.03 per year, 95% CI=1.01 to 1.04), a current or former (vs never) smoker (OR=2.36, 95% CI=1.46 to 3.80; OR=2.17, 95% CI=1.23 to 3.81) and with increasing alcohol consumption (OR=1.76 per score, 95% CI=1.59 to 1.95). One in two harmful drinking respondents (AUDIT-C score 10-12) reported appropriate advice/support. The likelihood was negatively associated with being woman (eg, OR=0.32, 95% CI=0.21 to 0.48), having a medium or high (vs low) education and with increasing household income.

CONCLUSIONS

A small proportion of hazardous and harmful drinking people in Germany report having ever received GP advice on, or support with, reducing alcohol consumption. The implementation of advice/support seems to be linked to specific socio-demographic characteristics, tobacco smoking and alcohol consumption level. Health policy measures should aim to increase alcohol screening, brief intervention rates and awareness for at-risk populations in primary care.

TRIAL REGISTRATION NUMBER

DRKS00011322, DRKS00017157.

The Effectiveness of E-Cigarettes for Smoking Cessation

BACKGROUND

Our primary aim was to assess-in the German population-the effectiveness of e-cigarettes (ECs; with or without nicotine), nicotine replacement therapy (NRT), and no use of evidence-based aids in smoking cessation.

METHODS

Analysis of cross-sectional data from a representative survey of the population (age 14-96 years) conducted in 2016-2021. All current smokers and recent ex-smokers (< 12 months since quitting) who had made ≥ 1 attempt to quit in the past 12 months (n = 2740) were included. They were asked about use of cessation aids in their most recent quit attempt and their current smoking status.

RESULTS

Two hundred thirty-nine respondents had used ECs, 168 NRT, and 2333 no aid. After adjustment for potential confounders, the odds of abstinence were 1.78 times higher for smokers who had used ECs in their quit attempt than in the group that had used no aids (95% confidence interval [1.09; 2.92]; p = 0.02) and 1.46 times higher than in the NRT group ([0.68; 3.13]; p = 0.34, Bayes factor = 1.26). Compared with the unaided group, the odds of abstinence were 2.34 times higher ([1.21; 4.53]; p = 0.01) in the subgroup using ECs with nicotine and 1.48 times higher ([0.68; 3.26]; p = 0.33) in the subgroup using ECs without nicotine. The unadjusted abstinence rates in people who had started their quit attempt > 6 months earlier were 15.6% [9.4; 23.8] in the ECs group and 13.8% [7.3; 22.9] in the NRT group.

CONCLUSION

In Germany, use of ECs in an attempt to quit smoking is associated with a higher rate of abstinence than attempting to quit unaided.

Exposure to Tobacco Smoking in Vehicles, Indoor, and Outdoor Settings in Germany: Prevalence and Associated Factors

Little is known on whether secondhand smoke (SHS) exposure in vehicles, indoor, and outdoor settings is similarly patterned in terms of different socio-epidemiological indicators in Germany. This study aims to estimate the current national-level prevalence and associated socio-epidemiological indicators of SHS exposure in vehicles, indoor, and outdoor settings in the German population, using current data from a representative household survey. We used cross-sectional data (N = 3928 respondents aged 14–99 years) from two waves of the DEBRA survey (German Study on Tobacco Use), conducted between January and March 2020. The reported prevalence of SHS exposure during the last seven days was 19% in vehicles, 25% in indoor settings, and 43% in outdoor settings. We found that younger age and current smoking were consistently associated with higher SHS exposure. Furthermore, people with low education were more likely to be exposed to SHS in vehicles and indoor settings than people with high education. This study found that the prevalence of SHS exposure in vehicles, indoor, and outdoor settings is a relevant feature of everyday life in Germany, especially for younger people and people with lower education, leading to potentially persistent socioeconomic and tobacco-attributable inequalities in morbidity and mortality.

Alcohol consumption and associations with sociodemographic and health-related characteristics in Germany: A population survey

BACKGROUND

To assess the prevalence of ever-drinking and hazardous drinking among adults in Germany, and investigate the factors associated with level of alcohol consumption.

METHODS

Cross-sectional population survey of a representative sample of 11,331 adults in Germany (2018 to 2019). The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) was used to define ever-drinking (AUDIT-C>=1), hazardous drinking (AUDIT-C>=5) and an overall AUDIT-C (alcohol consumption) score (from 0 to 12). Regression models were used to examine sociodemographic and health-related characteristics associated with AUDIT-C score.

RESULTS

The prevalence of ever-drinking and hazardous drinking was 84.7% (95% CI = 84.1-85.4) and 19.4% (95% CI = 18.6-20.1), respectively. The mean AUDIT-C score was 2.8 (SD = 2.16). AUDIT-C scores were independently positively associated with having medium (Badj = 0.12, 95% CI = 0.02-0.21) and high (Badj = 0.11, 95% CI = 0.01-0.21) educational qualifications (compared with low), monthly income (Badj = 0.31 per €1,000, 95% CI = 0.26-0.36), being a current smoker (Badj = 0.94, 95% CI = 0.86-1.02), anxiety (Badj = 0.26, 95% CI = 0.02-0.50), and living in North East (Badj = 0.43, 95% CI = 0.29-0.58), North West (Badj = 0.47, 95% CI = 0.39-0.55) and South East (Badj = 0.79, 95% CI = 0.64-0.93) Germany (compared with South West), and negatively associated with age (Badj = -0.17, 95% CI = -0.21- -0.13), being female (Badj = -1.21, 95% CI = -1.28- -1.14) and depression (Badj = -0.22, 95% CI = -0.43- -0.02).

CONCLUSION

In a large, representative sample of adults in Germany, the majority were ever-drinkers and one fifth were hazardous drinkers. Higher alcohol consumption scores were associated with being younger, male, current smoker, of high socioeconomic position, anxiety, and not living in South West Germany, and lower scores were associated with depression. These groups may benefit from targeted alcohol reduction policies and support.

Recreational Cannabidiol: Awareness, Prevalence of use, and Associated Factors in a Representative Sample of the German Population

BACKGROUND

Recreational cannabidiol (CBD) is frequently promoted as a medicinal or therapeutic cannabis product worldwide. Nationwide population-based data on awareness and use of recreational CBD are currently lacking.

OBJECTIVE

This study estimates the prevalence of recreational CBD awareness and use among the population in Germany. It also explores potential associations with socio-demographic characteristics, tobacco smoking, and e-cigarette use.

METHODS

We used data from a cross-sectional household survey (German Study on Tobacco Use, DEBRA) fielded across two waves in October-November 2020 and February-March 2021. Data were collected using computer-assisted face-to-face interviews among participants aged ≥14 years (n = 4026). Outcome variables were CBD awareness (yes/no) and CBD ever use (yes/no). The sample was weighted to ensure representativeness of the prevalence estimates. Associations with socio-demographic variables, tobacco smoking, and e-cigarette use were assessed using multivariable logistic regression.

RESULTS

Approximately half of the population in Germany (48.3%, 95% CI: 46.8-49.9) was aware of recreational CBD products, and 4.3% (95% CI: 3.7-5.0) had ever used them (including 1.1% current users). Awareness was associated with younger age, higher education levels, female sex, living in urban regions, no migration background, tobacco smoking, and e-cigarette use. Ever use was associated with higher education levels, living in urban regions, tobacco smoking, and e-cigarette use.

CONCLUSIONS

Awareness of recreational CBD products is high but ever use is currently low in Germany. Given the uncertain legal framework regarding the marketing of recreational CBD products, the changing retail landscape, and potential harms of CBD use, structured monitoring is warranted for public health purposes.

Externe Validierung einer Single-Item Skala zur Erfassung der Motivation zum Rauchstopp

Zusammenfassung. Zielsetzung: Die Motivation to Stop Scale (MTSS) ist eine englischsprachige Single-Item Skala zur Vorhersage von Rauchstoppversuchen. Ziel dieser Arbeit war die externe Validierung der deutschsprachigen Version der MTSS (Motivation zum Rauchstopp Skala, MRS) an einer Stichprobe von aktuell Tabakrauchenden in Deutschland. Methodik: Datenbasis war die Deutsche Befragung zum Rauchverhalten (DEBRA), eine deutschlandweite, persönlich-mündliche Haushaltsbefragung von Personen ab 14 Jahren mit telefonischer Nachbefragung nach 6 Monaten. Analysiert wurden Daten aus den ersten 18 Wellen (Juni 2016–Mai 2019) von 767 aktuell Tabakrauchenden. Die MRS (Stufe 1–7 = keine bis höchste Motivation) wurde bei der Erstbefragung eingesetzt. Bei der Nachbefragung wurde die Anzahl der Rauchstoppversuche seit Erstbefragung erfasst. Logistische Regression wurde durchgeführt und die diskriminative Genauigkeit der MRS mittels Area Under the Receiver Operating Characteristic Curve (ROC-AUC) berechnet. Ergebnisse: Bei Erstbefragung waren 61,1 % ( n = 469; 95 % Konfidenzintervall (KI) = 57.7–64.6) der 767 Rauchenden nicht zum Rauchstopp motiviert (MRS-Stufe 1–2). Insgesamt unternahmen 185 der 767 Rauchenden (24,1 %; 95 % KI = 21.1–27.1) zwischen der Erst- und Nachbefragung mindestens einen Rauchstoppversuch. Mit steigender Motivationsstufe auf der MRS nahm die Wahrscheinlichkeit für einen Rauchstoppversuch zu: Odds Ratio = 1.37, 95 % KI = 1.25–1.51, bei einer diskriminativen Genauigkeit von ROC-AUC = 0.64. Schlussfolgerung: Die MRS ist ein kurzes und valides Messinstrument zur Erfassung der Rauchstoppmotivation im deutschen Sprachraum.

Dental Nurses' Mental Health in Germany: A Nationwide Survey during the COVID-19 Pandemic

Several studies have found a rise in the rate of psychological discomfort among healthcare personnel since the COVID-19 pandemic outbreak. In this study, we analyzed the relationship between psychological variables of anxiety, depression, stress, avoidance, intrusion and hyperarousal and several factors among German dental nurses. For this poll, dental nurses were asked nationwide to take part via an online-based survey from July 2020 to January 2021. This survey gathered data on demographics, as well as psychological assessments through the Impact of Events Scale-Revised (IES-R) instrument, and the Depression Anxiety Stress Scales (DASS-21). The correlations between DASS-21/IES-R ratings and sociodemographic data were investigated using univariate analyses (Kruskal-Wallis and Mann-Whitney U tests). Single comparisons were performed using the Dunn-Bonferroni post hoc test if a relevant test result was significant followed by multiple linear regressions. Furthermore, 252 dental nurses took part in the study and showed overall normal or mild results of all psychological variables. Having immune-deficiency or chronic diseases, employment at a dental practice, being married, having no children and seeing the pandemic as a financial threat were presented as significant risk factors (p ≤ 0.05) with higher DASS-21 and IES-R scores. These results emphasize the aspects that must be considered to safeguard German dental nurses' mental wellbeing during the crisis.

Do people know that cigarette filters are mainly composed of synthetic material? A representative survey of the German population (the DEBRA study)

INTRODUCTION

Most cigarettes are smoked with filters made of synthetic plastic, which are not fully biodegradable. Littering used cigarette filters (butts) represents a substantial environmental hazard. It is unclear if people, in particular smokers, know that filters consist of synthetic plastic.

METHODS

We used data collected in August/September 2019 from a representative household survey of the German population aged 14 years and over (wave 20 of the German Study on Tobacco Use; DEBRA). Respondents were asked: 'The majority of smokers use cigarettes with a filter. What do you think these filters are composed of? (1) Mainly of natural material; (2) Mainly of synthetic material; (3) I don't know what cigarette filters are composed of.' Response option 2 indicated correct knowledge.

RESULTS

A total of 2066 people were interviewed, including 625 current smokers. The weighted response rate to option 2 ('mainly of synthetic material') was 34.8% (95%CI 32.7 to 36.9) in the total sample and 42.7% (95%CI=38.7 to 46.8) in the subgroup of current smokers. In the latter subgroup, smokers with low compared with those with high educational level were less likely to know that filters are mainly composed of synthetic material (OR=0.62, 95%CI=0.39 to 0.99).

CONCLUSIONS

The majority of smokers in Germany does not know that cigarette filters are mainly composed of synthetic material. Our findings suggest a need for promoting awareness as well as knowledge of environmental health hazards of cigarette filters to the general population, and specifically to current smokers.

TRIAL REGISTRATION NUMBER

DRKS00011322 and DRKS00017157.

Association between income and education with quit attempts, use of cessation aids, and short-term success in tobacco smokers: A social gradient analysis from a population-based cross-sectional household survey in Germany (DEBRA study)

INTRODUCTION

Smoking is more prevalent in smokers from lower compared with higher socioeconomic (SES) groups, but studies are inconsistent regarding underlying mechanisms. We aimed to assess associations between SES indicators and three distinct aspects of the smoking cessation process: attempting to quit; use of evidence-based cessation treatments; and success.

METHODS

We analysed data of 12,161 last-year smokers (i.e., current smokers and recent ex-smokers who quit ≤ 12 months) from 20 waves (June/July 2016 to August/September 2019) of the German Study on Tobacco Use (DEBRA) - a representative household survey. Associations between indicators of SES (income and education) and (1) last-year quit attempts; (2) use of evidence-based cessation treatment or electronic cigarettes during the last attempt; and (3) short-term self-reported abstinence were analysed using multivariable logistic regression, adjusted for potential confounders.

RESULTS

Of all last-years smokers, 18.6% had attempted to quit, of whom 15.2% had successfully stopped. Higher income (OR 0.82, 95%CI = 0.77-0.88 per 1000€) but low vs. high education (OR 0.83, 95%CI = 0.73-0.95) were associated with lower odds of quit attempts. In smokers with quit attempts, higher income but not education was associated with higher odds of using cessation medication (OR 1.31, 95%CI = 1.08-1.59 per 1000 €). Neither income nor education were associated with using behavioural support or success.

CONCLUSIONS

In the German healthcare system without free access to evidence-based cessation therapy, low-income smokers are more likely to make a quit attempt but less likely to use cessation medication than high-income smokers. Equitable access to such medication is crucial to reduce SES-related health disparities.

Waterpipe use and associated consumer characteristics in the German population: Data from a national representative survey (DEBRA study)

BACKGROUND

Waterpipes (WP) have a long tradition in certain regions of the world, and their use has been increasing worldwide. Current data on the use of WP in different subgroups of the German population are missing.

OBJECTIVE

To estimate the current prevalence of WP use and associated socio-demographic characteristics, tobacco smoking status and e-cigarette usage behaviour in the German population aged ≥14 years; to describe the frequency of use and starting age in current WP users.

METHODS

We analysed data from waves 13-18 (June/July 2018-April/May 2019; N = 12,220) of the German Study on Tobacco Use (DEBRA) - a representative, computer-assisted national household survey. Associations of socio-demographic characteristics, tobacco smoking status and e-cigarette usage behaviour were assessed with multivariable logistic regression models.

RESULTS

A total of 1.8% (n = 217) (95% confidence interval (CI) = 1.5%-2.0%) of the population were current WP users, 13% (n = 1618) (95% CI = 12.3%-13.5%) were ever users. Adjusted multivariable logistic models showed that people with migration background, male sex, younger age, and those who were smokers or used e-cigarettes, were more likely to use a WP. Among current WP users, 15.2% (n = 33) (95% CI = 10.7%-20.7%) had started to use WP at the age of 26 or older, and 23.0% (n = 50) (95%CI = 17.6%-29.2%) had used WP at least once a week or almost daily in the last month.

CONCLUSIONS

In Germany, the use of WP is popular and most strongly associated with migration background and use of tobacco and e-cigarettes. These aspects should be considered when designing future target group-specific prevention strategies.

Tobacco Use, Knowledge about Smoking-Associated Risks, and Cessation Programs among Dental Students in Germany - ToDent

BACKGROUND

Professional and consistent smoking prevention and cessation may avoid many smoking-associated deaths worldwide. Dentists can exert a decisive influence on smoking behavior, as most people regularly visit a dentist. However, only if dentists have been trained sufficiently about the consequences of smoking and of smoking cessation methods might they fulfill this task appropriately.

OBJECTIVES

The aim of our study was therefore to examine the prevalence of smokers among dental students in Germany, their attitude toward smoking in general, and their knowledge about tobacco-related diseases and smoking cessation programs.

METHODS

A cross-sectional survey among dental students in Germany was conducted in 2016. Students of the first and tenth semesters were asked to participate in this anonymous survey. The questionnaire included items concerning their own smoking habits, their knowledge about effects of smoking on health, and their attitude toward prevention and cessation in a dental setting.

RESULTS

Seven hundred and thirty dental students participated in this survey; 21% of the participating students were smokers. Their knowledge about smoking-related diseases was widespread. Some diseases were rarely known (only in 34% of students) and others were well known (in 99% of the students). Knowledge about health risks of e-cigarettes was low. About 30% of the participating students felt competent to encourage and support patients in cessation strategies; 2 out of 3 students were willing to improve their knowledge in that area. More than 85% confirmed that advice for smoking cessation should be one of the tasks of a dentist.

CONCLUSIONS

Smoking is common among dental students, their knowledge about smoking-related health risks is moderate, and self-perceived smoking cessation skills are poor. More emphasis should be placed on education regarding smoking prevention and cessation methods.

[Smoke-free Germany 2040: a discussion paper]

INTRODUCTION

A "smoke-free" society is assumed if less than 5 % of a population smoke. We predict when this goal could be reached in Germany. To reduce the proportion of smokers in the population, the World Health Organization recommends a bundle of measures (MPOWER) that should minimize both the supply of and the demand for tobacco. The current level of implementation of these recommendations in Germany is presented.

METHODS

A total of 21 representative cross-sectional surveys of the Drug Affinity Study and the Epidemiological Survey of Substance Abuse since 2000/2001 with adolescents and adults show the smoking behavior of the population until 2018. Per capita consumption of factory-built and self-made cigarettes during the same period is used as an objective data basis. Regression analyses are used to model the date at which less than 5 % of the German population smoke. A selective literature review is carried out to describe the implementation of the MPOWER program.

RESULTS

Before 2000 there was no trend in Germany towards non-smoking. After the implementation of various preventive measures such as price increases for tobacco products and the introduction of non-smoking protection laws, the spread of smoking among the population has steadily decreased since 2000. By 2018, the 5 % prevalence target among adolescents had almost been reached, as the relative proportion of adolescents who smoked fell by 20.9 percentage points to 6.6 %. The relative proportion of smoking in adult women fell by 12.1 percentage points to 18.5 %, the relative proportion of smoking in men by 14.8 percentage points to 24.2 %. Assuming a linear trend, the prevalence target of less than 5 % smoking adults can be reached by around 2043. Of the six recommended measures of the MPOWER program, Germany is currently only implementing the monitoring of tobacco consumption in society without compromises.

DISCUSSION

After various tobacco prevention measures were implemented, a trend towards non-smoking began in Germany. The continual price increase recommended by the World Health Organization, the further restriction of availability, the ban on all tobacco advertising and promotion, the support of smoking cessation as well as the education of the population appear to be necessary to reinforce this trend and to achieve the health policy goal of a smoke-free society in 2040.

Smoking Cessation Attempts and Common Strategies Employed

BACKGROUND

Clinical guidelines on smoking cessation contain recommendations for various evidence-based methods. The goal of this study was to provide a represen- tative analysis for Germany of the percentage of smokers who try to quit smoking at least once per year, the use of evidence-based methods and other methods of smoking cessation, and potential associations of the use of such methods with the degree of tobacco dependence and with socioeconomic features.

METHODS

Data from 19 waves of the German Smoking Behavior Questionnaire (Deutsche Befragung zum Rauchverhalten, DEBRA), from the time period June/July 2016 to June/July 2019, were analyzed. Current smokers and recent ex-smokers (<12 months without smoking) were asked about their smoking cessation attempts in the past year and the methods they used during the last attempt (naming more than one method was permitted). The degree of tobacco dependence in current smokers was assessed with the Heaviness of Smoking Index.

RESULTS

Out of 11 109 current smokers and 407 recent ex-smokers, 19.9% (95% confidence interval: [19.1; 20.6]) had tried to quit smoking at least once in the preceding year. 13.0% of them [11.6; 14.5] had used at least one evidence-based method during their last attempt. The stronger the tobacco dependence, the more likely the use of an evidence-based method (odds ratio [OR] = 1.27 [1.16; 1.40]). Pharmacotherapy (nicotine replacement therapy, medication) was used more com- monly by persons with higher incomes (OR = 1.44 per 1000 euro/month [1.28; 1.62]). Electronic cigarettes were the most commonly used single type of smoking cessation support (10.2 % [9.0; 11.6]).

CONCLUSION

In Germany, only one in five smokers tries to quit smoking at least once per year. Such attempts are only rarely supported by evidence-based methods and are thus likely to fail. The high cost of treatment must be borne by the individual and thus fall disproportionately on poorer smokers. It follows that there is an urgent need for vered by health insurance pro- viders, in order to give all smokers fair and equal access to the medical care they need.

[E-Cigarettes - Operating Principle, Ingredients, and Associated Acute Lung Injury]

Beginning in April of 2019, the US saw > 2,000 cases of hospitalized, often young, patients with severe acute lung injury, of which over 40 died, and the only existing connection between patients was their use of electronic cigarettes (e-cigarettes). The acronym EVALI ("e-cigarette, or vaping, product use associated lung injury") has since been established for the condition. This review article is intended to provide an overview of recent, mainly US literature on EVALI, including the case definition, epidemiology, clinical presentation, typical disease progression, as well as potential triggers. Ancillary to this, the review further provides a general overview of the basic function of e-cigarettes, the ingredients of the liquids used in these (e-liquids), as well as a brief description of the associated potential inhalation risks.

Economic burden of blindness and visual impairment in Germany from a societal perspective: a cost-of-illness study

BACKGROUND

Visual impairment and blindness cause a considerable and increasing economic burden affecting not only persons with vision loss and their families, but also societies. For the majority of countries, there is no solid database that would allow a comprehensive assessment of costs from a societal perspective. The present study was conducted to fill this gap.

OBJECTIVES

To investigate resource utilization of blind or visually impaired people and to assess the economic burden of blindness and visual impairment in Germany.

METHODS

This cross-sectional cost-of-illness study measures the economic burden of blindness and visual impairment bottom-up and from a societal perspective. Therefore, blind and visually impaired persons were recruited via national self-help organizations (prevalence-based approach) and interviewed regarding their utilized resources using various survey modes (mixed-mode approach). The observation period was 6 months retrospectively. Utilized resources were valued applying standardized unit costs (macro-costing). Calculations for the study population provided direct and indirect costs per person for a period of 6 months. Further cost per category was extrapolated to 1 year for the general population of Germany. Uncertainty of results was addressed applying univariate deterministic sensitivity analyses.

RESULTS

Complete data were collected from 683 participants (54.84% women; average age: 60.28 ± 17.02 years). Decreasing vision was associated with increasing costs (p < 0.001). Most costs were incurred by informal support from relatives, which was the most important resource for coping with everyday life for people with visual loss. Together with assistive/medical devices and loss of productivity due to disability, informal support accounted for 80% of total costs. Extrapolated to Germany, the annual costs of blindness and visual impairment from a societal perspective amounted to € 49.6 billion. Results of the sensitivity analyses and 95% confidence intervals showed a considerable degree of uncertainty.

CONCLUSION

Visual impairment and blindness may cause enormous overall costs from a societal point of view, as shown here for Germany. Our findings on the costs of blindness and visual impairment in Germany add in a number of different ways to the international evidence. In particular, results show that a large proportion of the costs are not obvious per se as it is caused by self-paid deductibles, productivity loss, early retirement and informal support/care by relatives. Further research should make special efforts to investigate these costs precisely as well as their influence factors.

Electronic Cigarettes to Vaporize Cannabis: Prevalence of Use and Associated Factors among Current Electronic Cigarette Users in Germany (DEBRA Study)

Background: In Germany, cannabis is the most widely used illicit drug, and inhalation together with tobacco is most popular. However, it has been described that electronic cigarettes (ECs) are being used to vaporize cannabis (extract). No current data on EC cannabis use in the German population are yet available. Objectives: This study examines the prevalence of EC cannabis consumption for mood changing effects among current EC users, and associated consumer characteristics in Germany. Methods: We used data from the German Study on Tobacco Use (period: 8/2016-01/2019, DEBRA, www.debra-study.info), a nationally representative household survey. EC cannabis use for mood-changing effects was assessed in 504 current EC users (aged ≥ 18 years) of the total sample (N = 32,678). Ever use was defined by: (1) occasional or regular use, or (2) experimental consumption. Associations with socio-demographic consumer characteristics and tobacco smoking were analyzed using multivariable regression analyses. Results: Amongst current EC users, 7.2% had ever vaporized cannabis: 2.3% (95%CI = 1.2-3.9) reported occasional or regular use (1) and 4.8% (95%CI = 3.2-7.1) reported experimental use (2). Age was associated with ever EC cannabis use: highest prevalence rates were found among 18-24-year-olds: 6.5% (95%CI = 2.3-13.1) (1) and 8.0% (95%CI = 3.7-15.8) (2), respectively. The majority (90.2%) of ever EC cannabis users were current tobacco smokers. Conclusions: One in 14 current EC users in Germany has ever vaporized cannabis for mood-changing reasons, and almost all EC cannabis consumers also smoke tobacco. Highest usage rates can be observed among young adults. Hence, trends of EC drug misuse need to be monitored consequently, particularly in young people.

STudy on E-Cigarettes and Pregnancy (STEP) - Study Protocol of a Mixed Methods Study on Risk Perception of E-Cigarette Use During Pregnancy and Sample Description

Introduction During pregnancy, the mother's healthy lifestyle is crucial for the health of the fetus. Potential risk factors for maternal and child health should therefore be identified and reduced as early as possible. The consumption of e-cigarettes represents one of these potential risk factors. Exploring risk perceptions about e-cigarette use during pregnancy can provide early indications of possible user motives. Therefore, our mixed methods ST udy on E -cigarettes and P regnancy (STEP) aimed to comprehensively analyze risk perceptions about e-cigarette use during pregnancy based on an I ntegrated H ealth B elief M odel (IHBM). This paper describes the study design, methods, sample population and limitations of STEP. Methods Our sequential mixed methods study combined qualitative and quantitative approaches. In the qualitative section of the study which preceded the quantitative part of the study, we aimed to characterize risk perceptions about e-cigarette use during pregnancy. We used a netnographic research approach which analyzed discussion threads in online forums dealing with e-cigarette use during pregnancy. The analysis was based on an IHBM. Identified themes were incorporated in the questionnaire which was developed for the quantitative part of the study. The quantitative section aimed to quantify, among other things, perceived threats, barriers and benefits and to explore differences in risk perception according to sociodemographic characteristics and tobacco and e-cigarette usage. Results In the qualitative section, 1552 posts in 25 online discussion threads dealing, inter alia, with e-cigarette use during pregnancy were identified. The quantitative part looked at the responses in the questionnaires handed in by 575 pregnant women who attended a hospital in Hamburg (Germany) from April 2018 to January 2019 (response rate: 27.5%). Conclusion Data collection was successful for both the qualitative and quantitative parts of the study. When interpreting the results of STEP, different limitations should be taken into account. The results of STEP provide starting points for the development of tailored preventive measures for pregnant women.

[Should advertising for electronic cigarettes and heated tobacco products be banned in Germany? Results of a representative survey (DEBRA study)]

BACKGROUND

The German federal parliament is discussing the implementation of a comprehensive tobacco advertising ban and whether that ban should include alternative nicotine delivery systems (ANDSs), such as e‑cigarettes and tobacco heaters. It would be important to know which outcome the general population, and in particular the users of tobacco/ANDSs, would prefer.

OBJECTIVE

Assessing public support for a comprehensive advertising ban on ANDSs in the German population, and particularly in tobacco and ANDSs users.

MATERIAL AND METHODS

The German Study on Tobacco Use ("Deutsche Befragung zum Rauchverhalten", DEBRA) is an ongoing, representative household survey of persons aged 14 years and older. Data from the June/July 2019 survey wave (n = 2019) were analysed. Participants were interviewed regarding their tobacco smoking status and ANDS use, sociodemographic factors, and their support of an advertising ban on ANDSs. Prevalence rates and associations (odds ratio, OR) between support and sociodemographic factors or use of tobacco/ANDSs are reported.

RESULTS

Of the population, 57.0% (95% confidence interval (95%CI) = 54.7-59.1%) support a ban on ANDS advertising; 11.1% (95%CI = 9.8-12.6%) reject it. There is support for the ban from 46.0% (95%CI = 42.2-49.9%) of current tobacco smokers and 42.7% (95%CI = 35.9-49.6%) of ANDS users. Ex-smokers show the highest rates of support (64.8%, 95%CI = 58.9-70.3%). Acceptance among never- and ex-smokers is higher than among current smokers (adjusted OR 2.06, 95%CI = 1.64-2.59 and OR 1.65, 95%CI = 1.23-2.21).

CONCLUSIONS

The majority of the German population supports a comprehensive advertising ban on ANDSs. Tobacco smokers and ANDS users are also more in favour of than against such a ban. Thus, only little resistance will be expected within the population if a comprehensive tobacco advertising ban, as currently discussed in parliament, includes e‑cigarettes and heated tobacco products.

Public attitudes towards healthcare policies promoting tobacco cessation in Germany: results from the representative German study on tobacco use (DEBRA study)

OBJECTIVE

The aim of this study was to assess public acceptance of four possible healthcare policies supporting tobacco dependence treatment in line with the Framework Convention for Tobacco Control, Article 14 recommendations in Germany.

DESIGN

Cross-sectional household survey.

SETTING

Data were drawn from the German population and collected through computer-assisted, face-to-face interviews.

PARTICIPANTS

Representative random sample of 2087 people (>14 years) from the German population.

OUTCOME MEASURES

Public acceptance was measured regarding (1) treatment cost reimbursement, (2) standard training for health professionals on offering cessation treatment, and making cessation treatment a standard part of care for smokers with (3) physical or (4) mental disorders. Association characteristics with smoking status and socio-economic status (SES) were assessed.

RESULTS

Support for all policies was high (50%-68%), even among smokers (48%-66%). Ex-smokers and never-smokers were more likely to support standard training on cessation for health professionals than current smokers (OR 1.43, 95% CI 1.07 to 1.92; OR 1.43; 95% CI 1.14 to 1.79, respectively). Ex-smokers were also more likely than current smokers to support cessation treatment for smokers with mental disorders (OR 1.39, 95% CI 1.11 to 1.73). Men were less likely than women to support cessation treatment for smokers with physical diseases (OR 0.74, 95% CI 0.60 to 0.91) and free provision of treatment (OR 0.80, 95% CI 0.66 to 0.97). Offering cessation treatment to smokers with physical disorders was generally more accepted than to those with mental health issues.

CONCLUSIONS

The majority of the German population supports healthcare policies to improve the availability and affordability of tobacco dependence treatment. Non-smokers were more supportive than current smokers of two of the four policies, but odds of support were only about 40% higher. SES characteristics were not consistently associated with public acceptance.

TRIAL REGISTRATION NUMBER

DRKS00011322.

Ärztliche Kurzberatung zur Tabakentwöhnung – Ergebnisse der DEBRA Studie

Zusammenfassung. Zielsetzung: Klinische Leitlinien empfehlen ärztliche Kurzberatung zur Tabakentwöhnung routinemäßig anzubieten. Repräsentative Daten zur Umsetzung in Deutschland und zu Assoziationen mit Soziodemographie und Rauchverhalten von Raucher/innen sollen erhoben werden. Methoden: Die Deutsche Befragung zum Rauchverhalten (DEBRA) erhebt zweimonatlich Daten in repräsentativen Bevölkerungsstichproben (je ~2.000 Personen, ≥14 Jahre) zu Tabak- und E-Zigarettenkonsum. In den ersten fünf Wellen seit Juni 2016 (10.225 Befragte) wurden Raucher/innen zu dem Erhalt von Rauchstoppberatung während des letzten Besuchs bei einer Hausärztin/einem Hausarzt (A) oder einer Ärztin/einem Arzt anderer Fachrichtung (B) befragt. Assoziationen mit Soziodemographie und Rauchverhalten wurden analysiert. Ergebnisse: Nach eigener Aussage von 2.910 Raucher/innen, hatten 72,8 % (95 %KI=71–74 %) eine Ärztin/einen Arzt des Fachgebiets A und/oder B konsultiert. Davon hatten 80,7 % (95 %KI=79–82 %) keine Rauchstoppempfehlung erhalten. 3,6 % (95 %KI=3–5 %) hatten ein evidenzbasiertes Therapieangebot bekommen. Starker Zigarettenkonsum und steigendes Alter waren mit dem Erhalt der Kurzberatung assoziiert (P<0,001), aber Bildung und Einkommen nicht. Es gab kaum Unterschiede zwischen Fachrichtung A und B. Schlussfolgerung: Der Erhalt leitliniengerechter ärztlicher Kurzberatung zur Tabakentwöhnung wird von Raucher/innen in Deutschland selten berichtet. Dringender Handlungsbedarf zur verbesserten Umsetzung der Leitlinienempfehlung besteht.

German Public Support for Tobacco Control Policy Measures: Results from the German Study on Tobacco Use (DEBRA), a Representative National Survey

Smoking prevalence in Germany remains high at approximately 28%. We assessed public support for tobacco legislation and associations between level of support and smoking and socio-demographic characteristics. Data from 2087 people were collected as part of the German Study on Tobacco Use ("DEBRA"): a nationally representative, face-to-face household survey. Public support was measured on total ban of sale, raising the minimum age for sales, taxation of tobacco industry sales, research into e-cigarettes, and ban of smoking in cars when children are present. Associations were assessed with multivariate logistic regression. Over 50% of the German population support taxing industry profits (57.3%) and assessing e-cigarettes as an aid to quit smoking (55.5%). Over 40% support raising the legal age of sale (43.1%), and 22.9% support a total ban on tobacco sales. A smoking ban in cars when children are present was most popular (71.5%), even among current smokers (67.0%). There is public support for stricter tobacco control measures in Germany. A smoking ban in cars when children are present could be a feasible policy to implement.

The Use of Tobacco, E-Cigarettes, and Methods to Quit Smoking in Germany

BACKGROUND

Current data on tobacco use are a necessary prerequisite for the study of the implementation of tobacco control measures in the general population. The German Study on Tobacco Use (Deutsche Befragung zum Rauchverhalten, DEBRA) provides previously lacking data on key indicators of smoking behavior and on the consumption of new products such as e-cigarettes. The continual acquisition and accumulation of data permits the analysis of trends and precise statistical evaluation.

METHODS

Data were obtained by repeated face-to-face interviews, at 2-month intervals, of representative samples of approximately 2000 persons across Germany aged 14 years and above. For this article, data from 12 273 persons that were acquired in 6 waves of the survey (June/July 2016 to April/May 2017) were aggregated and weighted.

RESULTS

The one-year prevalence of current tobacco consumption was 28.3% (95% confidence interval: [27.5; 29.1]) in the overall survey population and 11.9% [8.9; 14.9] among persons under age 18. Higher tobacco consumption was correlated with lower educational attainment and lower income. 28.1% of the smokers had tried to quit smoking in the past year; the most commonly used method of quitting was e-cigarettes (9.1%). Brief physician advice or pharmacotherapy for smoking cessation were tried by 6.1% and 7.0%, respectively. 1.9% of the overall survey population but only 0.3% of persons who had never smoked were current consumers of e-cigarettes.

CONCLUSION

Tobacco consumption is very high in Germany compared to other countries in Western and Northern Europe, and its distribution across the population is markedly uneven, with a heavy influence of socioeconomic status.