The Use of Alcohol, Tobacco, Illegal Drugs and Medicines
An estimate of consumption and substance-related disorders in Germany
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Background: Prevalence estimates of the use of tobacco, alcohol, illegal drugs, and psychoactive medications and of substance-related disorders enable an assessment of the effects of substance use on health and society.
Methods: The data used for this study were derived from the 2018 Epidemiological Survey of Substance Abuse (Epidemiologischer Suchtsurvey, ESA). The sample of the German adult population comprised 9267 persons aged 18 to 64 (response rate, 42%). Population estimates were obtained by extrapolation to a total resident population of 51 544 494 people.
Results: In the 30 days prior to the survey, 71.6% of the respondents (corresponding to 36.9 million persons in the population) had consumed alcohol, and 28.0% (14.4 million) had consumed tobacco. 4.0% reported having used e-cigarettes, and 0.8% reported having used heat-not-burn products. Among illegal drugs, cannabis was the most commonly used, with a 12-month prevalence of 7.1% (3.7 million), followed by amphetamines (1.2%; 619 000). The prevalence of the use of analgesics without a prescription (31.4%) was markedly higher than that of the use of prescribed analgesics (17.5%, 26.0 million); however, analgesics were taken daily less commonly than other types of medication. 13.5% of the sample (7.0 million) had at least one dependence diagnosis (12-month prevalence).
Conclusion: Substance use and the consumption of psychoactive medications are widespread in the German population. Substance-related disorders are a major burden to society, with legal substances causing greater burden than illegal substances.
Substance use is associated with a multitude of health and social effects. The results of the Global Burden of Disease Study clearly demonstrate that alcohol and tobacco use are among the main risk factors worldwide for premature mortality and life years lost due to disease and disability (1, 2). In 2015, every third person in Western Europe reported at least one episode of heavy drinking (≥ 60 g ethanol) in the preceding 30 days, every fifth person smoked tobacco daily, and 7% of respondents stated that they had consumed cannabis in the previous 12 months (3). Prevalence rates for the use of other illegal drugs such as amphetamines (0.6%), cocaine (1.1%), and opioids (0.4%) were much lower (3).
The consumption of psychoactive substances is associated with an increased risk for substance disorders. The number of individuals with a substance-related dependence per 100 000 people was estimated to be 881 for alcohol and 425 for cannabis in Western Europe in 2015. The number of deaths caused by substance use was reported to be 78 for tobacco, 19 for alcohol, and seven for illegal drugs per 100 000 people in the population (3).
The Epidemiological Survey of Substance Abuse (Epidemiologischer Suchtsurvey, ESA) yields population-representative data on the prevalence of legal and illegal substance use, hazardous forms of use, as well as substance-related disorders according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Projected prevalence estimates for various indicators of use make it possible to quantify the current burden caused by substance use and substance-related disorders.
Study design and sample
The 2018 ESA study population is made up of German-speaking individuals aged between 18 and 64 years living in private households in Germany. The sample was drawn in a two-stage selection process. In a first step, 254 municipalities (sample points) were randomly selected. In a second step, addresses were drawn from the respective population registers using a systematic random selection. Data was collected by means of written and online questionnaires or telephone interviews (mixed-method design). The adjusted sample included 9267 individuals (response rate = 41.6%). See the eMethods section for a detailed description of the methods used (mode effects, non-response analyses).
Tobacco, e-products, and heat-not-burn products
Prevalence estimates for the use of traditional tobacco products, such as cigarettes, cigars, cigarillos, and pipes, water pipes (hookahs), e-cigarettes, e-hookahs, e-pipes, e-cigars, and heat-not-burn products (tobacco heaters), are based on the preceding 30 days (4). Daily cigarette consumption is defined as daily use of at least one cigarette and heavy cigarette consumption as daily use of at least 20 cigarettes (30-day prevalence).
Prevalence estimates of alcohol consumption in the preceding 30 days were made using a beverage-specific quantity–frequency index. 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 (5, 6).
The 12-month prevalence for the use of illegal drugs was assessed for cannabis (hashish, marijuana), amphetamine and methamphetamine, ecstasy, LSD, heroin, other opiates, cocaine/crack cocaine, hallucinogenic mushrooms, and new psychoactive substances (NPS).
The prevalence values for the use of medicines in the preceding 30 days, as well as their daily use, were recorded for analgesics, hypnotics or sedatives, analeptics, anorectics, antidepressants, and neuroleptics. Respondents allocated each medication they had taken to one of the categories in a list of the most common types of preparations.
Abuse and dependence were recorded as substance-related disorders according to DSM-IV (7) criteria for the use of alcohol, cannabis, cocaine, amphetamine, analgesics, as well as hypnotics and sedatives. The items in the Munich Composite International Diagnostic Interview (M-CIDI) were used for the purposes of classification. Dependence is the only diagnosis defined for tobacco.
Descriptive data on substance use in the form of prevalence estimates with 95% confidence intervals are presented separately for the total population, as well as for men and women. In order to align the data with the distribution of the adult German population, all analyses were weighted (according to age, sex, education level, federal state, and municipality size class). The population size of 51 544 494 people (26 149 029 men; 25 395 465 women) as of 31.12.2017 was used for simple projections by extrapolation to the resident population aged between 18 and 64 years (10). Due to the complex sample design, standard errors were estimated using Taylor series (e1). All analyses were performed using Stata 14.1 (Stata Corp LP; College Station, TX, USA).
Tobacco, e-products, and heat-not-burn products
The prevalence of use of traditional tobacco products within the preceding 30 days was 23.3% (12.0 million individuals) and the prevalence of daily tobacco use was 15.1% (7.8 million individuals) (Table 1). Of the tobacco users, 23.4% (2.8 million) reported smoking more than 20 cigarettes a day. The prevalence of water pipe smoking was 4.2% (2.2 million individuals). In all, 4.0% (2.1 million individuals) reported using e-cigarettes and 0.8% (412 000 individuals) heat-not-burn products. Higher prevalence rates were seen among men compared to women across all three product categories.
A total of 71.6% of respondents (36.9 million individuals) stated that they had consumed alcohol in the preceding 30 days (Table 2). Of those that had consumed alcohol, 34.5% reported at least one episode of heavy drinking, with the prevalence for men (42.8%) being higher compared to women (24.6%). The prevalence of alcohol use in hazardous quantities was 18.1%, whereby there was no statistically significant difference between the prevalence among men (16.7%) and that among women (19.7%).
With a 12-month prevalence of 7.1% (3.7 million individuals), cannabis was the most frequently used illegal drug, followed by amphetamine at 1.2% (619 000 individuals) (Table 3). The use of cocaine/crack cocaine and ecstasy was each reported by 1.1% of respondents. Methamphetamine had the lowest prevalence at 0.2%. Sex differences in substance use were largely not statistically significant—only for cannabis and illegal drugs in general was consumption higher among men compared to women.
In the 30 days prior to the survey, prescription (17.5%; 9.0 million) as well as over-the-counter analgesics (31.4%; 16.2 million individuals) were the most commonly used medicines, with significantly higher prevalence rates among women than among men (Table 4). Antidepressants were the second most frequently used prescription medicines at 4.1% (2.1 million individuals). Of the over-the-counter medicines, hypnotics and sedatives (2.0%; 1.0 million individuals) were the second most commonly used. If prescribed by a physician, women took antidepressants significantly more frequently than men. The percentages for the daily use of prescription antidepressants (87.7%) and neuroleptic agents (78.0%) were the highest. The daily use of non-prescription medications was significantly lower.
With a 12-month prevalence of 8.6% (4.4 million individuals), tobacco dependence as defined in DSM-IV was the most common substance-related disorder, followed by analgesic (3.2%; 1.6 million individuals) and alcohol dependence (3.1%; 1.6 million individuals) (Table 5). The prevalence rates for dependence on illegal drugs as well as hypnotics/sedatives were both under 1.0%. The percentage for analgesic abuse was highest at 7.6%, followed by alcohol abuse at 2.8%. With the exception of analgesic dependence (men: 2.7%; women: 3.6%), substance-related disorders were more common in men compared to women.
In all, 13.5% of respondents exhibited at least one of the dependence disorders shown in Table 5, which corresponds to 7.0 million 18- to 64-year-olds in the population. Excluding tobacco dependence, 6.7% of respondents, or 3.5 million individuals, qualified for a dependence disorder (data not shown).
With 14.4 million current smokers, tobacco use is widespread in Germany. As such, the percentage of current smokers in Germany is significantly higher compared to Belgium, the Netherlands, Great Britain, Ireland, Denmark, Sweden, and Finland, with a prevalence that holds a mid-position among European Union countries (11). Tobacco use is associated with significant risks for cancer as well as cardiovascular, respiratory, and vascular diseases (12, 13, e2). The total number of tobacco-related deaths in Germany in 2013 was estimated at 121 000, with more deaths among men (85 000) compared to women (36 000) (12). Based on the 2018 ESA data, one can assume that 4.4 million of 18- to 64-year-olds in Germany are tobacco-dependent.
Although the use of electronic inhalation products has increased in Germany (14–16), the prevalence rates for e-cigarette and heat-not-burn product use are still low at 4.0% and 0.8%, respectively. The DEBRA study reported similar rates for e-cigarette use (17, 18). Since the aerosol produced by e-cigarettes contains fewer harmful substances than the smoke from traditional tobacco cigarettes, e-cigarette use is associated with fewer health risks for smokers (19). However, studies on the long-term health effects of e-cigarettes are still lacking. E-cigarettes are often used for smoking cessation and are therefore primarily used by smokers (14, 18, 20, e3). An analysis of ESA data from 2015 showed that 11% of smokers were able to quit with the help of e-cigarettes (14). However, a number of studies suggest that the use of e-cigarettes increases the risk among former smokers and non-smokers, in particular adolescents, of (re-)starting the use of traditional combustible tobacco products (19, 21, e4, e5).
In international comparisons, Germany is one of the high-consumption countries with a pro capita consumption of 10.7 liters of pure alcohol (3), which leads to high alcohol-related morbidity and mortality (22). While heavy alcohol consumption increases the long-term risk for a number of non-communicable diseases, e.g., cardiovascular diseases and cancer (23), episodic heavy drinking is a risk factor for acute effects such as falls or traffic accidents, as well as irreversible damage to the brain and nervous system (24–26). Moreover, third parties may suffer injury, e.g., due to alcohol consumption during pregnancy or as a result of traffic accidents. For example, the annual number of children born with fetal alcohol spectrum disorders (FASD) in Germany is estimated to be 12 650, and 45.1% of all third-party deaths in traffic accidents (e.g., pedestrians) can be causally attributed to alcohol consumption (27). The present study revealed approximately 3.1% of respondents to be alcohol-dependent, which corresponds to 1.6 million individuals in the population. The annual economic cost of alcohol consumption in Germany is estimated at 26.7 billion Euro, compared to the far lower tax revenues from the alcohol tax of 3.2 billion Euro (28, 29, e6).
In an international comparison, the 12-month prevalence of cannabis use in Germany of 7.1% is in line with the total European average (30). Cannabis dependence was found in 0.6% of study participants. Prescription of cannabis medication by physicans was legalized in Germany in 2017. Against the backdrop of the current political debate on regulation, a recent study emphasizes the fact that the health risks of cannabis consumption should not be underestimated (31). For example, there is a link between cannabis use and the development of anxiety disorders and depression, and there is also an increased risk for the re-emergence of bipolar symptoms (e7, e8). Furthermore, the marked increase in the concentration of tetrahydrocannabinol (THC) in recent years is accompanied by incalculable health risks (32).
At 1.2%, the prevalence of amphetamine use in Germany was more than twice the European total (0.5%) (30). Interestingly, the prevalence for new psychoactive substances (NPS) (0.9%) is higher than for methamphetamine (0.2%). A regional comparison also shows that methamphetamine use was statistically significantly more widespread in Saxony, Thuringia, and Bavaria in 2015 compared to other German federal states, whereas NPS use was almost evenly distributed across federal states (33). The higher methamphetamine prevalence in the regions close to the Czech Republic has been confirmed by recent wastewater analyses. Compared to other cities investigated in the study, Dresden has the highest inhabitant-specific load (34).
In order for medicines to confer a therapeutic benefit, they need to be used as prescribed and not over a long time period (35, 36). This applies not only to addictive analgesics, but also to over-the-counter non-opioid analgesics, for instance. Incorrect use over a longer period of time (≥ 15 days/month) can cause medication-overuse headache and promote the use of further painkillers, thereby in turn increasing the likelihood for developing medication abuse or dependence (36). Projections put the number of analgesic-dependent 18- to 64-year-olds at 1.6 million. Analyses using the ESA data from 2015, which make a distinction between opioid and non-opioid analgesics, estimated the prevalence of opioid analgesic use disorders according to DSM-V at 1% and the percentage of all mental disorders caused by analgesics at 12% (37). According to the available evidence, the majority of analgesic dependence disorders can be attributed to non-opioid analgesics that were obtained either by private prescriptions or as pharmacy-only medications. This share can be explained by the high prevalence of use combined with the psychological dependence potential of non-opioid analgesics (36). The prevalence of hypnotic/sedative use (30 days) in the population is much lower than that for analgesics, which is reflected in the lower prevalence of dependence disorders.
The vast majority of antidepressants and neuroleptic agents used were prescribed by a physician (population prevalence). The clearly low figures for the daily use of almost all medicines not prescribed by a physician suggests that abuse of these medication groups, with the exception of analgesics, is rare. With regard to analgesics, the high concordance between the population estimate on daily use (1.9 million individuals) and the estimate on analgesic dependence (1.6 million individuals) clearly demonstrates the high dependence potential of these medications.
By virtue of its multi-method design, complex sample, and suitable sample size, the 2018 Epidemiological Survey of Substance Abuse yields reliable, population-representative data on the general adult population aged 18–64 years. Biases may be caused by the systematic non-participation of certain user groups (38). For example, non-responders who filled in the non-response-questionnaire more often exhibited problematic consumption patterns, such as episodic heavy drinking, compared to study participants, but had a lower prevalence for overall consumption (eMethods). Therefore, consumption prevalence is likely to be overestimated and the prevalence of problematic consumption patterns underestimated. Limitations also arise from the fact that the responses of those questioned differ according to the survey method used, and that the estimates are based on self-reported information (38, 39, e9). When interpreting the results, one must bear in mind that the present study design precluded the possibility of reaching population groups such as homeless individuals or prison inmates in whom higher prevalence rates for substance use and substance-related disorders are assumed (40). Consequently, the fact that certain subgroups are inaccessible increases the underestimation of reported prevalence rates on substance use with increasing subgroup marginalization.
In summary, the results of this study indicate that substance use and hazardous consumption patterns are widespread in the general German population and that substance-related disorders, particularly due to legal substances such as tobacco and alcohol, as well as over-the-counter analgesics, represent a considerable burden on society.
The 2018 Epidemiological Survey of Substance Abuse (ESA) was funded by the German Federal Ministry of Health (Bundesministerium für Gesundheit, BMG) (ref: ZMVI1–2517DSM200). Funding is not subject to conditions.
Conflict of interest statement
The authors state that they have no conflicts of interest.
Manuscript submitted on 3 April 2019, revised version accepted on 24 June 2019.
Translated from the original German by Christine Rye.
Dipl.-Soz., B. Sc. Psych. Josefine Atzendorf
IFT Institut für Therapieforschung
80804 München, Germany
Cite this as:
Atzendorf J, Rauschert C, Seitz NN, Lochbühler K, Kraus L:
The use of alcohol, tobacco, illegal drugs and medicines—an estimate of consumption and substance-related disorders in Germany. Dtsch Arztebl Int 2019; 116: 577–84. DOI: 10.3238/arztebl.2019.0577
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Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Ungarn:
Prof. Dr. phil. Ludwig Kraus
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