Demographic ageing and the evolution of smoking-attributable mortality: the example of Germany

Burden of smoking on disease-specific mortality, DALYs, costs: the case of a high-income European country

BACKGROUND

Smoking is a major risk factor for chronic diseases causing early death and disability. Smoking prevalence over the past 25years has remained high in Switzerland. Evidence about the burden of disease and cost of illness attributable to smoking can support tobacco control. The aim of the present paper is to quantify from a societal perspective the mortality, disability-adjusted life years (DALYs), medical costs and productivity losses attributable to smoking in Switzerland in 2017.

METHODS

Smoking attributable fractions (SAFs) were calculated based on the prevalence of current and former active smoking in the latest Swiss Health Survey from 2017 and relative risks from the literature. The SAFs were then multiplied with the number of deaths, DALYs, medical costs and productivity losses in the total population.

RESULTS

In the Swiss population in 2017 smoking accounted for 14.4% of all deaths, for 29.2% of the deaths due to smoking-related diseases, 36.0% of the DALYs, 27.8% of the medical costs and 27.9% of productivity losses. Total costs amounted to CHF 5.0 billion which equals CHF 604 per capita per year. The highest disease burden in terms of mortality and DALYs attributable to smoking was observed for lung cancer and chronic obstructive pulmonary disease (COPD), whereas the highest cost of illness in terms of medical costs was observed for coronary heart diseases and lung cancer and in terms of productivity losses for COPD and coronary heart diseases. Sex and age group differences were found.

CONCLUSIONS

We provide an estimate of the burden of smoking on disease-specific mortality, DALYs, medical costs and productivity losses in Switzerland that could be prevented through evidence-based tobacco prevention and control policies as well as regular monitoring of tobacco consumption.

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.

The Use of Psychoactive Substances in Germany

BACKGROUND

Monitoring the use of psychoactive substances and substance-related problems in the population allows for the assessment of prevalence and associated health and social consequences.

METHODS

The data are derived from the Epidemiological Survey of Substance Abuse (ESA) 2021 (n = 9046, 18-64 years). We estimated prevalence rates of the use of tobacco, alcohol, illegal drugs, and psychoactive medications, as well as the prevalence rates of their problematic use (indicating dependence) using screening instruments, and extrapolated the results to the resident population (N = 51 139 451).

RESULTS

Alcohol was the most frequently used substance, with a 30-day prevalence of 70.5% (36.1 million people), followed by non-opioid analgesic drugs (47.4%; 24.2 million) and conventional tobacco products (22.7%; 11.6 million). E-cigarettes were used by 4.3% (2.2 million) and heat-not-burn products by 1.3% (665 000). Among illegal drugs (12-month prevalence), cannabis was the most frequently used (8.8%; 4.5 million), followed by cocaine/crack (1.6%; 818 000) and amphetamine (1.4%; 716 000). Rates of problematic use among the study participants were 17.6% for alcohol (9.0 million), 7.8% for tobacco (4.0 million), 5.7% for psychoactive medications (2.9 million), and 2.5% for cannabis (1.3 million).

CONCLUSION

The consumption of psychoactive substances continues to be widespread in Germany. In view of the imminent legal changes, the high prevalence of cannabis use and its problematic use need to be taken into consideration.

Impact of tobacco control policies implementation on future lung cancer incidence in Europe: An international, population-based modeling study

BACKGROUND

Despite recent trends in declining smoking rates, tobacco smoking remains the most preventable cause of cancer in Europe. We aimed to estimate numbers and proportions of future lung cancer cases that could be potentially prevented over a 20-year period if countries in Europe were to achieve a comprehensive implementation of tobacco control policies.

METHODS

Historical data from population-based cancer incidence (or mortality) was used to predict sex-specific lung cancer incidence for 30 European countries up to 2037. Hypothetical country-specific smoking prevalence that would be expected if countries would have achieved the highest-level implementation of tobacco control policies (defined by the maximum total score of the Tobacco Control Scale, TCS) was estimated by combining national prevalence data on current smoking and data on the status of implementation of key tobacco control policies. Resulting numbers and proportions of potentially preventable lung cancer cases were estimated taking into account latency periods between changes in smoking prevalence and excess cancer risks.

FINDINGS

In Europe, an estimated 1·65 million lung cancer cases (21·2%, 19·8% in men and 23·2% in women) could be prevented over a 20-year period with the highest-level implementation of tobacco control policies. Large variation was seen in European regions and countries reflecting the current level of tobacco control, with the largest potential for prevention in Western Europe (24·5%), Southern Europe (23·1%) and Eastern Europe (22·5%), and the lowest but still substantial potential for further prevention in Northern Europe (12·5%). In women, among whom lung cancer incidence is expected to increase, we estimated somewhat larger proportions of preventable lung cancer cases ranging from 9·9 to 33·9% as compared to men (8·6-28·5%). In the final year of study period (2037), these proportions even exceed 50% in women for some countries.

INTERPRETATION

Improved and expanded implementation of evidence-based tobacco control policies at the most comprehensive level could reduce future lung cancer incidence considerably across Europe.

FUNDING

The study was funded by the German Cancer Aid ("Deutsche Krebshilfe"), grant number 70112097.

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.

Trends in cancer incidence and survival in the Augsburg study region-results from the Augsburg cancer registry

OBJECTIVES

Knowledge about time trends of cancer incidence and cancer survival in a defined region is an essential prerequisite for the planning of regional healthcare infrastructure. The aim of the study was to provide population-based analyses of all common tumour sites to assess the cancer burden in the Augsburg study region.

SETTING

Total population of the study region of Augsburg (668 522 residents), Southern Germany.

PARTICIPANTS

The data obtained from the Cancer Registry Augsburg comprised 37 487 incident cases of malignant tumours (19 313 men and 18 174 women) diagnosed between 2005 and 2016 in the Augsburg region's resident population.

PRIMARY AND SECONDARY OUTCOME MEASURES

We calculated sex-specific, age-standardised incidence rates and annual percent change to assess time trends. In men and in women, 3-year and 5-year relative survival was calculated and results were compared with the latest German estimates. Survival trends were presented for the most common cancers only.

RESULTS

Decreasing age-standardised incidence rates were observed for prostate cancer and for colorectal cancer in men. For oropharyngeal cancer, rates declined in men, but significantly increased in women. Incidence for female breast cancer remained stable. Five-year relative survival ranged between 6.4% (95% CI: 4.1% to 10.1%) for pancreatic cancer and 97.7% (95% CI: 96.0% to 99.4%) for prostate cancer in men and between 10.2% (95% CI: 7.1% to 14.6%) for pancreatic cancer and 96.6% (95% CI: 93.6% to 99.6%) for malignant melanoma in women. Trends in 3-year survival of the five most common tumour sites in men showed a significant increase for lung and oropharyngeal cancer. In women, continuously rising survival trends were observed for breast cancer.

CONCLUSIONS

Survival of cancer patients in the Augsburg study region was largely concordant with the situation in Germany as a whole, while incidence showed slight deviations in some cancer sites. Regional evaluations on cancer survival are a valuable instrument for identifying deficits and determining advances in oncological health management.

Impact of a smoking cessation program on smoking prevalence and food security among food pantry users - a study protocol for a pragmatic cluster randomised controlled trial

BACKGROUND

Among food pantry users there is a high prevalence of both smoking and food insecurity, which may be related to one another. This study aims to evaluate the impact of a smoking cessation program carried out in food pantries on the smoking status and the food security status of food pantry users.

METHODS / DESIGN

Before starting the cluster randomised controlled trial, stakeholders will be engaged to adapt a behavioural group counselling program for smoking cessation to the needs of the food pantry users in a pre study. Food pantry users and workers as well as other experts, such as smoking cessation trainers, social workers, and psychologists, will be involved, using the world café technique and telephone interviews and a qualitative thematic analysis for data analysis to design the concept of the intervention program will be applied. In the second phase, the impact of the intervention on the smoking status and on food insecurity will be investigated by a cluster randomised controlled trial. A total of 416 food pantry users across 32 clusters (food pantries) in Berlin, Germany, should be recruited and randomly assigned to either the intervention group or the waiting list control group. The intervention will consist of a behavioural group counselling program for smoking cessation, specially tailored for food pantry users, as well as optional nicotine replacement therapy and the implementation of environmental smoking reduction measures in the food pantries. The primary outcomes 6 months after the treatment will be self-reported continuous smoking abstinence, validated by exhaled carbon monoxide (< 10 ppm of carbon monoxide), and increased food security level (the percentage of participants with an improved food security level).

DISCUSSION

This study will be the first long-term investigation into the effect of a smoking cessation program on smoking status and food insecurity. The results of this study will inform the implementation of smoking cessation programs in food pantries throughout Germany.

TRIAL REGISTRATION

Prospectively registered DRKS00020037 . Registered 29 April 2020.

Effectiveness of an innovative and interactive smoking cessation training module for dental students: A prospective study

BACKGROUND

Smoking is one of the world's major health problems and dental professionals are in a unique position to promote smoking cessation. However, according to the current literature, neither dental students nor dentists feel adequately prepared to counsel smokers. The purpose of this study was to develop and implement a teaching intervention on smoking cessation for fourth-year dental students and assess its effectiveness in terms of learning outcome on knowledge, communication skills and attitudes.

MATERIALS AND METHODS

In this prospective intervention study, students in the intervention group (n = 28) participated in a teaching module consisting of a podcast, an interactive lecture, a seminar, and small-group sessions with role-play interactions. Knowledge, communication skills and attitudes were measured using written examinations and an objective structured clinical examination (OSCE) at the end of the module and 6 months later. Results were compared with data from a historical control group (n = 27) receiving standard teaching.

RESULTS

Compared with the control group, students in the intervention group had higher scores in the knowledge test (67.1% vs 41.8%; P < .001; d = 2.8) as well as in the OSCE (74.9% vs 44.7%; P < .001; d = 2.3) and also retained more knowledge (52.7% vs 36.5%; P < .001; d = 2.0) and skills (71.8% vs 47.6%; P < .001; d = 2.5) over a period of 6 months. Attitudes were similar across groups and time-points.

CONCLUSION

The teaching intervention equipped dental students with specific knowledge and skills required to effectively counsel smoking patients. Further research is required to assess the transfer of these skills to the clinical setting.

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.

ESTIMATING AND FORECASTING THE SMOKING-ATTRIBUTABLE MORTALITY FRACTION FOR BOTH GENDERS JOINTLY IN OVER 60 COUNTRIES

Smoking is one of the leading preventable threats to human health and a major risk factor for lung cancer, upper aero-digestive cancer, and chronic obstructive pulmonary disease. Estimating and forecasting the smoking attributable fraction (SAF) of mortality can yield insights into smoking epidemics and also provide a basis for more accurate mortality and life expectancy projection. Peto et al. (1992) proposed a method to estimate the SAF using the lung cancer mortality rate as an indicator of exposure to smoking in the population of interest. Here we use the same method to estimate the all-age SAF (ASAF) for both genders for over 60 countries. We document a strong and cross-nationally consistent pattern of the evolution of the SAF over time. We use this as the basis for a new Bayesian hierarchical model to project future male and female ASAF from over 60 countries simultaneously. This gives forecasts as well as predictive distributions that can be used to find uncertainty intervals for any quantity of interest. We assess the model using out-of-sample predictive validation, and find that it provides good forecasts and well calibrated forecast intervals, comparing favorably with other methods.

[Trends in smoking among adults in Germany : Evidence from seven population-based health surveys from 1991-2015]

BACKGROUND

Despite decreasing smoking prevalence, tobacco use remains a key public health problem in Germany. For planning, managing, and evaluating tobacco control measures, regular data collection on smoking behavior in the population is essential. The aim of this article is to present trends in adult tobacco use since the early 1990s based on data from the health monitoring of the Robert Koch-Institute (RKI).

METHODS

Analyses are based on data from 106,158 individuals aged 18 to 79 years, who participated in seven RKI health surveys from 1991-2015. Trends in tobacco consumption were analyzed using different indicators of smoking behavior, stratified by age, cohort, and gender.

RESULTS

An overall falling smoking prevalence can be attributed primarily to a significant decline in the younger age groups since the early 2000s. Trend analysis by cohort reveals a declining prevalence for almost all cohorts over time from 1991-2015. Historically there has been is a sharp increase in the prevalence of women who have ever smoked between the 1930-1934 and 1950-1959 cohorts. The proportion of men who have ever smoked slightly decreased between the 1930-1934 and 1980-1984 cohorts.

DISCUSSION

The shown overall decline happened concurrently with various tobacco prevention measures implemented during this period in Germany. If present trends related to continuous high smoking rates are sustained, it can be assumed that the tobacco consumption of the population will remain the source of adverse health outcomes. Accordingly, tobacco prevention measures and the promotion of smoking cessation in all age groups should be a public health priority.

Effectiveness of training general practitioners to improve the implementation of brief stop-smoking advice in German primary care: study protocol of a pragmatic, 2-arm cluster randomised controlled trial (the ABCII trial)

Background

The German clinical guideline on tobacco addiction recommends that general practitioners (GPs) provide brief stop-smoking advice to their patients according to the “5A” or the much briefer “ABC” method, but its implementation is insufficient. A lack of training is one barrier for GPs to provide such advice. Moreover, the respective effectiveness of a 5A or ABC training regarding subsequent delivery of stop-smoking advice has not been investigated. We developed a training for GPs according to both methods, and conducted a pilot study with process evaluation to optimize the trainings according to the needs of GPs. This study aims at evaluating the effectiveness of both trainings.

Methods

A pragmatic 2-arm cluster randomised controlled trial with a pre-post data collection will be conducted in 48 GP practices in North Rhine-Westphalia (Germany). GPs will be randomised to receive a 3.5-h-training in delivering either 5A or ABC, including peer coaching and intensive role plays with professional actors. The patient-reported primary outcome (receipt of GP advice to quit: yes/no) and secondary outcomes (recommendation rates of smoking cessation treatments, group comparison (5A versus ABC): receipt of GP advice to quit) will be collected in smoking patients routinely consulting their GP within 4 weeks prior, and 4 weeks following the training. Additional secondary outcomes will be collected at 4, 12 and 26 weeks following the consultation: use of cessation treatments during the last quit attempt (if so) since the GP consultation, and point-prevalence abstinence rates. The primary data analysis will be conducted using a mixed-effects logistic regression model with random effects for the cluster variable.

Discussion

If the training increases the rates of delivery of stop-smoking advice, it would offer a low-threshold strategy for the guideline implementation in German primary care. Should one method prove superior, a more specific guideline recommendation can be proposed.

Trial registration

German Clinical Trials Register (DRKS00012786); registered on 22th August 2017, prior to the first patient in.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0986-8) contains supplementary material, which is available to authorized users.

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.

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.