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Official websites use. Share sensitive information only on official, secure websites. 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. Alcohol was the most frequently used substance, with a day prevalence of E-cigarettes were used by 4. Among illegal drugs month prevalence , cannabis was the most frequently used 8. Rates of problematic use among the study participants were 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. The use of psychoactive substances is one of the main risk factors for the global burden of disease and premature mortality 1. In , worldwide tobacco use was responsible for approximately million disability-adjusted life years DALY and 8. A total of 2. Thus, based on the total number of annual deaths Despite an observed decline in the consumption of alcohol since the s, Germany is among the 10 countries worldwide with the highest per capita consumption rates 4 , 5. The proportion of smokers in was also above the West European average 6. In addition to the high burden of morbidity and mortality, the use of psychoactive substances is associated with significant economic costs, which cannot be compensated for through tax revenue from the sale of legal substances alcohol, tobacco. According to estimates, the consumption of alcohol in Germany generates annual costs to the economy of approximately The total direct and indirect costs to the economy of tobacco use in were estimated at The annual expenditure for illicit drug use in Germany in was put at 5. Monitoring the use of psychoactive substances is an indispensable precondition of health policy decision-making and enables, among other things, an estimation of future costs and the evidence-based development of effective prevention and intervention measures. As a population-representative study, the German Epidemiological Survey of Substance Abuse ESA provides data on the use of both legal and illegal substances as well as on hazardous forms of use in the German adult population. The aim of this paper is to provide prevalence estimates of the use of tobacco, alcohol, illicit drugs, and psychoactive medications and of negative consequences of substance use in the German adult population. The target group of the ESA comprises German-speaking individuals aged 18—64 years and living in private households. Sampling was performed using a two-stage selection process. In a first step, municipalities were randomly selected. A random selection of addresses was then made from the respective population registers. In order to make up for the low proportion of young adults in the total population, disproportionate sampling according to age cohorts was carried out. The survey was conducted in writing, via the internet, or by telephone. The adjusted sample comprised individuals, the response rate was For further information on the methodology used for the ESA , the procedure of the survey, the response rate by study arm, as well as prevalence rates according to survey mode, see eMethods , eFigure , and eTables 1 — 3. The use of conventional tobacco products cigarettes, cigars, cigarillos, and pipes , waterpipes hookahs , e-cigarettes, e-waterpipes, e-pipes, e-cigars, and heat-not-burn products was surveyed for the preceding 30 days Daily cigarette consumption was defined as the use of at least one cigarette per day, while heavy cigarette consumption was defined as the use of at least 20 cigarettes per day. Episodic heavy drinking was defined as the consumption of five or more glasses of alcohol approximately 70 g pure alcohol on at least one day in the preceding 30 days. The daily consumption of more than 12 g women and 24 g men of pure alcohol was defined as the threshold for hazardous alcohol consumption 11 , The use of analgesics, hypnotics and sedatives, analeptics, anorectics, antidepressants, and neuroleptic drugs was surveyed for the preceding day period. Medications taken on a daily basis were also recorded. Statistically significant differences in prevalence estimates were measured using confidence intervals. Projections to the total resident population in Germany aged 18—64 years were performed based on a population of 51 individuals 25 men; 25 women as of 31 December e6. Post-stratification weights were used to adjust the data to the distribution of the target population in the German adult population in terms of the characteristics age, sex, school education, federal state, and community size class. Due to the complex sample design, the Taylor series linearization method was used to estimate standard errors e7. The day prevalence of conventional tobacco product use was Of the tobacco users, Waterpipe use was reported by 4. Men showed higher prevalence rates across all product categories compared to women. Evidence of dependence on tobacco products was seen in 7. A total of Of these, Among alcohol consumers, Differences between prevalence rates among men Overall, With a month prevalence of 8. In total, 1. With a prevalence of 2. In this group, men were more frequently affected with a prevalence of 3. Sex differences in the month prevalence of these substances were not statistically significant. Non-opioid analgesics were the medications most commonly used, with a day prevalence of The second most commonly used medications were reported to be hypnotics or sedatives 5. In total, Among the users of the respective medication group, antidepressants Non-opioid analgesics were the medications most rarely used daily 6. Finally, With the proportion of smokers exceeding a fifth Thus in , of the 27 EU Member States plus Great Britain , Germany ranked 16th on a list in descending order of smoking prevalence Smoking is one of the largest preventable risk factors for a multitude of physiological diseases including, cardiovascular and respiratory diseases as well as cancer and is considered to be the cause of around deaths each year in Germany Studies show that only total abstinence from smoking can be considered as harmless to health e8. In view of this, it is even more concerning that only one in five German smokers reports attempts to quit The same study shows that e-cigarettes both with and without nicotine as an alternative to smoking are the most commonly used single form of aid during any attempt to quit smoking. According to recent evidence, e-cigarette vaporization is less harmful to health than smoking tobacco cigarettes 17 , but it is not considered safe In particular adolescents and young adults are at increased risk for taking up e-cigarette use—and thus also for the associated health risks—due to the multitude of flavors on offer Overall, the percentage of e-cigarette users among the adult population is relatively low at 4. However, the prevalence rates among young adults of exclusive use of alternative products, such as heat-not-burn products, waterpipes hookah , or e-cigarettes, are markedly higher compared to those among older age groups With a day prevalence of The consumption of large quantities of alcohol has been shown to be associated with an increased risk for a wide range of non-communicable diseases e9. While the consumption of high-risk amounts of alcohol over a prolonged period of time is associated in particular with chronic diseases for example, cardiovascular disease or cancer , episodic heavy drinking predominantly leads to acute diseases and injuries, including harm to others as a result of traffic accidents or alcohol use during pregnancy 21 , Studies also suggest that blackouts caused by binge drinking, particularly in adolescents, can increase the risk of an alcohol use disorder, in addition to massive brain and nervous system damage 23 , The available results show that A rise in the prevalence of use in recent years has been reported both throughout Europe 26 and in Germany 5. A comparison of the last ESA survey in also shows a further increase in the month prevalence of cannabis use by 1. Since , medical cannabis has been available on prescription in Germany for certain indications. With approximately 30 to 40 users of medical cannabis in Germany 28 , the majority of the estimated 4. In particular the regular use of cannabis has been shown to be associated with an increased risk for mental health disorders for example, anxiety disorders, psychoses, depression 29 , In view of the current political debate on legalization in Germany, one should not underestimate the risks and hazards of cannabis use especially to adolescents and young adults 31 , The results of the present study show that one in four cannabis users exhibits problematic use. With the exception of cannabis, the use of other illegal drugs in Germany is much less widespread. Cocaine is the second most commonly used illegal substance; with a prevalence of 1. The use of NPS 1. With around These pain medications that are available over the counter from pharmacies are used primarily to treat mild to moderate pain, but can cause serious side effects if used improperly 34 , The prevalence of non-opioid analgesic abuse among self-medicated users is estimated to be 6. In contrast, the percentage of people using prescription opioid analgesics is, as expected, lower at 2. Analyses of prescription data show a constant rise in the total number of opioid analgesic prescriptions over the last decade According to the results of this study, approximately 2. One can assume that—in addition to opioid analgesics— hypnotics and sedatives are particularly associated with problematic use, since these drugs have a high dependence potential by virtue of their pharmacological properties Survey data on prevalence rates of use are subject to a number of limitations. For example, one can expect biases due to systematic non-participation by certain user groups see eMethods Section for non-response analyses. Since all information on substance use is based on self-reporting, the full picture may be underestimated as a result of socially desirable response behavior. With regard to the representativeness of the present study, it is important to note that due to the study design, certain population groups are difficult or impossible to reach. This applies in particular to individuals aged over 64 years, homeless people, as well as people receiving inpatient treatment. The use of illegal and legal psychoactive substances remains widespread in Germany. Alcohol is the most frequently used psychotropic substance, followed by non-opioid analgesics and tobacco. Cannabis is the most commonly used illegal substance. Against the backdrop of the planned legislative changes 40 , the high prevalence rates of cannabis use as well as its problematic use are likely to spark discussion. The target population of the Epidemiological Survey of Substance Abuse ESA was made up of German-speaking people aged between 18 and 64 years born between and living in private households, and covers approximately The sample of persons was drawn in two stages. In the first stage, municipalities or sample points were randomly drawn based on municipal statistical data from the German Federal Statistical Office and the statistical offices of the German federal states. Sample points represent equally sized clusters of people drawn directly from the civil registers of the municipalities in the second stage. Municipalities were drawn within stratification cells from the combination of ten municipality size classes while controlling for the distribution of government districts and states. The number of sample points was converted proportionally to the resident population in the age cohorts. Therefore, cities can be represented by several sample points in the sample. A total of sample points were drawn from communities, whereby 25 communities were unable or unwilling to provide addresses. The missing municipalities were made up for with additional draws from the other municipalities. Overall, municipalities sample points submitted addresses. Personal addresses were drawn from the population registers by systematic random selection. The uneven distribution of age cohorts in the population required a disproportionate approach, meaning that younger age cohorts were more likely to be selected given that they were not as strongly represented as were older age cohorts. Taking into consideration the disproportionate sample design and the anticipated sample-neutral dropouts per municipality, addresses per sample point were selected. This equated to a gross sample of 30 individuals. In order to increase the response rate and minimize the selectivity of the sample, the survey used a mixture of methods comprising written postal surveys, online surveys, and telephone surveys. All target persons received written correspondence comprising study information, a data privacy statement, an online access code, and an accompanying letter from the German Federal Ministry of Health. Target persons in the telephone study arm were notified by a trained interviewer that they would be contacted. In the case of an unsuccessful attempt at telephone contact, a written questionnaire was sent in addition to a reminder letter. Individuals in the written study arm received the questionnaire with a postage-prepaid return envelope. If the target persons failed to respond, two reminders were sent at four-week intervals. At any time, respondents were able to switch between survey modes or request an additional written questionnaire. The online questionnaire could be answered on a variety of mobile devices, such as smartphones or tablets. The aim of the survey was to record the use of legal and illegal substances and related problems. In addition to information on the use of tobacco, alcohol, illicit drugs, and psychoactive medications, information was also gathered on physical and mental health status, chronic diseases, mental health disorders, and sociodemographics. Both the online survey and the telephone survey were based on the written questionnaire. It was sometimes necessary in the online survey to optimize the layout and presentation of certain question batteries for mobile devices. In an additional module in the online survey, cannabis users were asked in-depth questions about their use of cannabis. The full questionnaire can be found at www. Sociodemographic characteristics were recorded in line with the demographic standards of the German Federal Statistical Office e Information on the following was gathered: sex and year of birth, migrant background country of birth and citizenship of the respondent and their parents, family situation marital status, children, household size , education schooling, vocational training , employment employment status, occupational position and net household income. Applicable diseases could be specified from a list. These related to the preceding 12 months and included the presence of psychosomatic complaints, anxiety disorders panic, generalized anxiety disorder, social phobia, specific phobia, fear of public places , depression, mania, and post-traumatic stress disorder, as well as psychiatric, psychological, or psychotherapeutic treatment or a finding of mental or psychosomatic illness. Both day and month prevalence rates were collected for all substances. The lifetime prevalence was recorded for the use of all substances except medications. The survey included conventional tobacco products such as cigarettes, cigars, cigarillos, and pipes, as well as smoking and tobacco alternatives such as e-cigarettes these include e-cigars, e-waterpipes, and e-pipes , tobacco heaters, and waterpipes hookahs. With the exception of waterpipes, the number of days of use in the preceding 30 days as well as the average amount used per day of use were recorded for these products alongside prevalence. This was derived from data on the number of days on which the respective beverages were consumed and the number of units consumed on a typical day of consumption. To calculate the amount of pure alcohol in grams, the per-liter data for the beverages were used based on the beverage-specific alcohol contents and the number of units consumed. The beverage-specific alcohol contents beer: 4. For alcoholic mixed beverages, the average alcohol content of a glass 0. An individual average daily amount was derived from the calculated pure alcohol in grams. Five categories were formed on the basis of recommended daily limits for low-risk alcohol consumption:. NPS are substances that imitate the effects of illegal drugs, such as cannabis, ecstasy, cocaine, etc. Prior to the questions, each drug group was presented using a list of the most common preparations in order to help respondents classify the drugs they use. In addition to use, the frequency of hypnotics, sedatives, analeptics, anorectics, antidepressants, neuroleptics, and anabolics was also recorded with the following answer categories:. In relation to the preceding 30 days, respondents were asked whether or not the medication had been prescribed by a physician. The prevalence and frequency of analgesic use were recorded in the same way, but separately for opioid and non-opioid analgesics. In relation to the preceding 12 months, respondents were asked whether these drugs had been prescribed exclusively, partially, or not at all by a physician. Problematic substance use indicating dependence in the 12 months prior to the interview was recorded using substance-specific screening scales. The items in the substance-specific screening scales were only given to those respondents that had reported use of the respective substance or relevant medication in the preceding 12 months. Most of the participants in the telephone arm answered the questionnaire online In this arm, Participants in the written study arm were those most likely to use the written postal questionnaire Only 0. The response rate was calculated as the proportion of realized cases in the initial sample, with the latter being adjusted for neutral dropouts with no systematic influence on sample selection. The shares of response statuses shown in eTable 1 for both study arms form the basis for the calculation of response rate. These include evaluable questionnaires The latter relates to individuals that were in principle available for the study, but did not participate, i. These systematic dropouts were significantly higher in the telephone study arm than in the written arm In both arms, most dropouts were due to refusal to participate or non-contactable status. In the course of the data review, a further 63 cases needed to be excluded from the cases realized. Thus the number of valid and evaluable cases came to individuals. In order to be able to make representative statements for the German population aged between 18 and 64 years using the ESA , three weights were calculated: one design weight and one redressement weight each for cross-sectional analyses and trend analyses. The design weight is intended to offset the disproportionate sampling according to age cohorts and is inversely proportional to the selection probability. This weighting factor takes a minimum value of 0. The effect of weighting is evaluated using the effectiveness measure E and the resulting effective sample size. The effective sample size tells us how large a simple random sample without weighting could have been in order to yield results of comparable precision to the complex sample e17 — e This means that, due to the complex sample design required for Germany-wide representativeness, the effectiveness of the realized sample fell to This level of effectiveness is comparable to similar studies e The redressement weights are intended to adjust the marginal distributions of certain external characteristics to the population; this minimizes bias due to non-response. An iterative proportional fitting algorithm is used to this end e The design weights are contained in the redressement weights. The redressement weight of the cross-sectional analyses adjusts the marginal distributions of the characteristics federal state, district size, sex, and highest school-leaving qualification in the to year-old population to the microcensus e The inclusion of further characteristics increases the variance of the weighting factors, which range in value from 0. This yields an E of Again, this level of effectiveness is comparable to that in similar studies e The survey mode in the ESA could be freely chosen, meaning that mode effects need to be taken into consideration. Almost half Participants differed on the basis of sociodemographic variables. Whereas in the telephone interview the weighted percentages of men and women were largely balanced The average age of participants was 47 years for telephone interviews, 42 years for the written survey, and 40 years for the online survey. The weighted percentage of individuals with a general qualification for university entrance was higher in the online Here, individual characteristics that influence the choice of survey mode were controlled for. It becomes apparent that in particular internet-based responses significantly differ from responses made in the written survey. Only in the prevalence of alcohol use in the preceding 30 days and hypnotics in the preceding 12 months are there no significant differences across survey methods. Participants in the written postal survey show higher prevalence rates in all substances compared to those in the online survey. In particular, one sees a higher day prevalence of smoking In order to better assess non-response bias, non-participants were asked to respond to a short one-page questionnaire. In all, individuals expressed their willingness to do so. With the exception of the prevalence of tobacco use, statistically significant differences between the two populations can be seen. For example, the prevalence of episodic heavy drinking in the preceding 30 days is higher among non-participants On the other hand, the lifetime and month prevalence rates of cannabis use are lower among non-participants compared to participants The aim of the Epidemiological Survey of Substance Abuse is to enable population-representative statements on substance use and problematic patterns of use in the general population aged 18—64 in Germany. Using weightings, the distribution of the characteristics federal state, municipality size class according to the German system for classifying municipalities , sex, birth cohort, and schooling is adjusted to the distribution in the population. Biases in the analyses due to non-response were minimized by these weightings as well as by making a variety of survey methods available. The number of participants in the ESA of corresponds to the desired sample size. At This can be attributed to a higher proportion of target persons compared to The analysis of mode effects on the prevalence of the various substances points to differences between survey modes also when controlling for sociodemographic variables. In contrast to self-completed questionnaires, either in writing or online, telephone surveys are conducted by interviewers. In addition, the non-response analysis showed statistically significant differences between participants and non-participants. The differences point in a similar direction to those in the ESA However, the results of the comparison need to be interpreted with caution, since only 5. One can assume that individuals with an interest in the topic participated in the survey. In the case of substances that are largely socially normalized, such as alcohol, tobacco, as well as cannabis, one can assume fairly low biases in general prevalence estimates. It is important to note that highly marginalized groups of people homeless individuals or prison inmates are not part of the target population, since they do not live in private homes. However, in these and other subgroups, it is safe to assume that consumption behavior is high and excessive in some cases. Thus, one can assume a possible underestimation of prevalence rates for substance use as well as consumption patterns with higher distribution in these groups of people. Funding is not subject to conditions. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. Dtsch Arztebl Int. Find articles by Christian Rauschert. Nicki-Nils Seitz , Dr. Find articles by Nicki-Nils Seitz. Nicolas Wilms , B. Find articles by Nicolas Wilms. Sally Olderbak , Dr. Find articles by Sally Olderbak. Ludwig Kraus , Prof. Find articles by Ludwig Kraus. PMC Copyright notice. See letter ' Clear Definitions Exist ' in volume on page See letter ' In Reply ' in volume on page Open in a new tab. Written Telephone Total Initial sample 19, 11, 30, Evaluable questionnaires following data validation Instruments The aim of the survey was to record the use of legal and illegal substances and related problems. Sociodemographics Sociodemographic characteristics were recorded in line with the demographic standards of the German Federal Statistical Office e Substance use Both day and month prevalence rates were collected for all substances. Use of tobacco and smoking alternatives The survey included conventional tobacco products such as cigarettes, cigars, cigarillos, and pipes, as well as smoking and tobacco alternatives such as e-cigarettes these include e-cigars, e-waterpipes, and e-pipes , tobacco heaters, and waterpipes hookahs. Medication use Prior to the questions, each drug group was presented using a list of the most common preparations in order to help respondents classify the drugs they use. In addition to use, the frequency of hypnotics, sedatives, analeptics, anorectics, antidepressants, neuroleptics, and anabolics was also recorded with the following answer categories: In relation to the preceding 30 days, respondents were asked whether or not the medication had been prescribed by a physician. Problematic substance use Problematic substance use indicating dependence in the 12 months prior to the interview was recorded using substance-specific screening scales. Response rate The response rate was calculated as the proportion of realized cases in the initial sample, with the latter being adjusted for neutral dropouts with no systematic influence on sample selection. Weighting In order to be able to make representative statements for the German population aged between 18 and 64 years using the ESA , three weights were calculated: one design weight and one redressement weight each for cross-sectional analyses and trend analyses. Mode effects The survey mode in the ESA could be freely chosen, meaning that mode effects need to be taken into consideration. Non-response effects In order to better assess non-response bias, non-participants were asked to respond to a short one-page questionnaire. Representativity The aim of the Epidemiological Survey of Substance Abuse is to enable population-representative statements on substance use and problematic patterns of use in the general population aged 18—64 in Germany. Conflict of interests statement The authors declare that no conflict of interests exists. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Evaluable questionnaires following data validation. Non-evaluable questionnaires following data validation.

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