Psychoactive Substance Use in Germany

Findings From the Epidemiological Survey of Substance Abuse (ESA) in 2024

Background: Monitoring the use of psychoactive substances and the prevalence of substance-related disorders in the general population enables estimation of the extent of substance abuse and its effects on health and society.

Methods: Data are from the Epidemiological Survey of Substance Abuse (ESA) for 2024 (n = 7534, aged 18–64 years). Prevalence rates were calculated for the use of tobacco, alcohol, cannabis, illegal drugs, and medications, and for individuals who met the DSM-IV criteria for dependency or abuse. Rates were extrapolated to the German resident population aged 18 to 64 (51 480 168 people).

Results: The most commonly used substance was alcohol, with a 30-day prevalence of 68.6% (35.3 million people), followed by non-opioid analgesics (31.5%) and conventional tobacco products (21.8%). The 12-month prevalence of cannabis use was 9.8% (5.1 million people). Dependence prevalences were 4.2% for alcohol, 8.3% for tobacco, 1.0% for cannabis, 0.1% for amphetamines, 0.1% for cocaine, 2.8% for analgesics, and 1.5% for hypnotics and sedatives. Abuse prevalences were 5.6% for analgesics, 0.5% for cannabis, 0.1% for cocaine, 0.1% for amphetamines, 1.1% for hypnotics and sedatives, and 3.3% for alcohol.

Conclusion: The use of psychoactive substances in Germany is still widespread. Because of the effects of psychoactive substance use on health and society, continual monitoring is essential for the early detection of trends and the institution of targeted preventive and interventional measures.

Cite this as: Olderbak S, Hollweck R, Krowartz EM, Möckl J, Hoch E: Psychoactive substance use in Germany: Findings from the Epidemiological Survey of Substance Abuse (ESA) in 2024. Dtsch Arztebl Int 2025; 122: 625–31. DOI: 10.3238/arztebl.m2025.0157

The use of alcohol, tobacco and other psychoactive substances is one of the leading risk factors for physical and mental disease as well as premature mortality worldwide (1). In Germany, in 2021, approximately 99 000 persons died as a result of smoking or prolonged exposure to secondhand smoke (2) and 21 700 persons aged 15 to 69 years died as a result of their alcohol consumption (3). Since 2017, the number of deaths related to the use of illegal substances, such as heroin, cocaine and synthetic drugs, has been rising continuously. In 2023, the number of drug-related deaths reached an all-time high of 2227 cases, corresponding to an increase of 12% compared to the previous year (4).

Despite the trend of declining alcohol use, which started in the 1990s, Germany remains one of the countries with the highest per capita alcohol consumption worldwide (5). In addition, a decline in tobacco use has been noted over the last decade: The per capita cigarette use in Germany fell from 1022 cigarettes in 2010 to 785 cigarettes in 2022 (6). In recent years, a number of alternative nicotine products, such as e-cigarettes, has been brought to market. The exposure to secondhand smoke is a health risk, regardless of whether the source is conventional tobacco cigarettes or e-cigarettes and related products. About 8% of adult non-smokers are exposed to secondhand smoke at least once a week and about 4% are exposed daily (7). According to estimates from 2005, which are based on data from 2003, approximately 3300 non-smokers died in Germany as a result of secondhand smoke exposure (8).

The purpose of collecting data on the use of psychoactive substances in a systematic way is to create a central resource for developing effective health policy measures. Using this approach, it is possible to estimate the burden on the healthcare system and develop targeted strategies for prevention and treatment. The Epidemiological Survey of Substance Abuse (ESA) is designed to regularly provide representative data on the use of psychoactive substances among the adult population in Germany. The aim of this article is to present information on the frequency of use of tobacco, alcohol, cannabis and illegal substances, as well as medications and to provide an overview of the associated health risks.

Methods

Study design and sampling

The 2024 ESA Survey sampled German-speaking adults aged 18 to 85 years living in private households in Germany. In our analysis, we focused on respondents aged 18 to 64 years (n = 7534) to ensure comparability with previous ESA survey waves. A two-stage selection procedure was used for sampling. The survey was carried out between August and December 2024, allowing respondents to complete the survey in writing, online, or over the phone. The initial sample size was calculated based on an assumed response rate of 25%; the empirical response rate was slightly lower at 22.0%. Our analyses are based on self-reported information by the respondents (For detailed information on methods used for the 2024 ESA survey see the eSupplement).

Instruments

Conventional tobacco products, hookahs, and alternative nicotine delivery systems

Consumption of conventional tobacco products (cigarettes, cigars, cigarillos, and pipes), hookahs and alternative nicotine delivery systems (e-cigarettes, e-hookahs, e-pipes, e-cigars, and heat-not-burn products) was recorded for the period of the last 30 days (9). Daily cigarette use was defined as smoking at least one cigarette per day, while heavy cigarette use was defined as smoking at least 20 cigarettes every day in the 30 days preceding the survey.

Alcohol

The amount of alcohol consumed during the last 30 days was determined using a beverage-specific frequency–quantity index for beer, wine/sparkling wine, spirits, and mixed alcoholic beverages. Binge drinking was defined as consuming five or more alcoholic drinks (approximately 70 g of pure alcohol) on at least one day during the last 30 days. Thresholds for risky alcohol consumption were defined for women and men as daily consumption of more than 12 g and 24 g pure alcohol, respectively (10, 11).

Cannabis

Data on the use of cannabis (hashish, marijuana, and other cannabis products containing more than 0.3% THC) was collected in relation to the period of the last 12 months preceding the survey. Thus, the new legal regulation, under which cannabis is no longer classified as an illegal substance in Germany as of 1 April 2024, fell within the survey period (12).

Illegal drugs

The use of amphetamine and methamphetamine, MDMA (“ecstasy“), LSD, heroin, other opioids (e.g., codeine, methadone, opium, morphine), cocaine/crack, hallucinogenic mushrooms, and new psychoactive substances (NpS) was recorded for the period of the last 12 months preceding the survey. The variable “at least one of these drugs“ included the consumption of at least one illegal substance within the last 12 months. Two operationalizations of this variable were considered: one with and one without cannabis to ensure comparability with previous survey waves.

Medication

The use of non-opioid analgesics, opioid analgesics, hypnotics or sedatives, analeptics (stimulants), anorectics, antidepressants, neuroleptics, and medicinal cannabis (cannabis flowers or cannabis products) was recorded for the period of the last 30 days preceding the survey. Data on which medications were taken daily was also collected. Using a list of the most commonly used medications, the respondents independently assigned these medications to the respective medication groups.

Dependence and abuse according to DSM-IV

The Munich Composite International Diagnostic Interview (M-CIDI) was used to assess abuse of and dependence on conventional tobacco products, alcohol, cannabis, cocaine, amphetamine, analgesics (non-opioid and opioid-containing), as well as hypnotics and sedatives (13). For conventional tobacco products, only dependency was recorded.

Statistical analyses

Descriptive data on substance use and data on substance abuse and dependence are presented as prevalence estimates with corresponding 95% confidence intervals and reported both for the total population and stratified by gender. Projections for the total German resident population aged 18–64 years are based on the current population statistics (as of 31 December 2023) reporting 51 480 168 persons (14). Given the small number of persons who stated their gender as “diverse“ (n = 33), gender-stratified analyses were performed for men and women only. Since the total results include all persons, female and male case numbers do not add up to the total sample size (n). We used post-stratification weights to adjust the data to the distribution of the underlying German adult population with regard to age, gender, education, federal state, and municipality size. Given the complex sample design, we estimated the standard error using Taylor series linearization which allows robust variance estimation for weighted and stratified samples (15) (for further details see the eSupplement). The statistical software Stata 15.1 SE was used for the data analyses (16).

Results

Conventional tobacco products, hookahs and alternative nicotine delivery systems

The 30-day prevalence of the use of conventional tobacco products was 21.8% (11.2 million persons), while the proportion of daily users was 9.3% (4.8 million) (Table 1). Of the persons consuming conventional tobacco products, 14.8% (1.7 Mio.) stated that they smoke at least 20 cigarettes daily and 8.3% (4.3 Mio.) of the total population met the criteria for dependence on conventional tobacco products (eTable). During the last 30 days, 1.7% of the respondents (875 000 persons) had used hookahs, while 8.3% (4.27 million) had used e-cigarettes/e-hookahs/e-pipes/e-cigars and 1.9% (978 000) had used heat-not-burn products. In all product categories, except heat-not-burn products, prevalence rates were higher in men compared to women. Across all categories, 28.2% (14.5 million persons) stated that they had used at least one product type in the last 30 days.

Table 1

The 30-day prevalence of consumption of conventional tobacco products, hookahs and alternative nicotine delivery systems as well as extrapolations to the population aged 18 to 64 years

eTable

The 12-month prevalence of substance-related disorders according to DSM-IV and extrapolation to the population aged 18 to 64 years

Alcohol

68.6% of the respondents (35.3 million persons) reported to have consumed alcohol in the last 30 days (Table 2). Of these, 27.0% (9.5 million) reported at least one episode of binge drinking, with a higher prevalence among men (35.5%) compared to women (16.9%). 24.4% of the respondents (8.6 million persons) reported to have consumed risky amounts of alcohol during the last 30 days. 4.2% (2.2 million) of the total population met the criteria for alcohol dependence. The prevalence of alcohol abuse was 3.3% (1.7 million) (eTable).

Table 2

The 30-day prevalence of alcohol consumption and extrapolation to the population aged 18 to 64 years

Cannabis

The 12-month prevalence of cannabis use was 9.8% (5.0 million persons); it was higher in men (12.3%) compared to women (7.1%) (Table 3). 1.0% percent of the total population (515 000) met the criteria for cannabis dependence and 0.5% (257 000) for cannabis abuse (eTable). The findings on cannabis use are presented in greater detail in the article by Hoch et al. (17).

Table 3

The 12-month prevalence of drug consumption and extrapolation to the population aged 18 to 64 years

Table 4

The 30-day prevalence of medication use and daily use; extrapolation to the population aged 18 to 64 years

Illegal drugs

A total of 3.7% of respondents (1.9 million persons) reported to have consumed at least one illegal drug in the last 12 months. Of these, 1.1% (566 000 persons) reported the use of crack/cocaine and 1.0% (515 000) reported the use of ecstasy. The 12-month prevalence of other illegal drugs was less than 1% (Table 3). The criteria for cocaine dependence were met by 0.1% (51 000) and for cocaine abuse also by 0.1% (51 000) (eTable). The criteria for amphetamine dependence were met by 0.1% (51 000) and for amphetamine abuse also by 0.1% (51 000).

Medications

A total of 40.6% of respondents (21 million persons) reported having used at least one of the medications listed in the survey in the last 30 days. With a 30-day prevalence of 31.5% (16.2 million), non-opioid analgesics were the most commonly used medication, followed by hypnotics/sedatives (6.3%; 3.2 million), antidepressants (6.3%; 3.2 million) and opioid analgesics (3.8%; 2.0 million). Among users of drugs included in the various medication groups, 89.6% of the respondents (2.9 million) reported taking antidepressants on a daily basis, followed by neuroleptics (87.0%; 761 000), analeptics (51.4%; 291 000), and opioid analgesics (40.7%; 796 000). Daily intake of medications such as antidepressants is generally prescribed for therapeutic purposes and not associated with abuse or dependence. Analgesic abuse was noted in 5.6% (2.9 million), while 2.8% (1.4 million) met the DSM-IV criteria for dependence. In the hypnotics/sedatives group, 1.1% (566 000) had symptoms of abuse and 1.5% (772 000) symptoms of dependence (eTable).

Discussion

Conventional tobacco products, hookahs, and alternative nicotine delivery systems

While the proportion of persons aged 18 to 64 years who consumed conventional tobacco products during the last 30 days has declined compared to 2021, it remains at a high level (18). The proportion of daily smokers in Germany was 9.3% which is below the European average of 18.4% (19). According to scientific evidence, there is no risk-free exposure to tobacco and the mortality risk is higher even in persons with low tobacco consumption (20, 21, 22). In Germany, nicotine is the substance associated with the highest rates of dependence. Yet only 7.6% of smokers reported that they had made at least one serious attempt to quit smoking in the last 12 months (23).

Alcohol

The most used psychoactive substance in Germany is alcohol. Alcohol consumption is an established causal risk factor for more than 200 different disease entities, including cancer, cardiovascular diseases, and mental health impairments (24). Alcohol is the second most common reason for a diagnosis of substance dependence in Germany: According to extrapolations, approximately 2.2 million people met the DSM-IV criteria for dependence and 1.7 million people met the criteria for abuse in 2024. The World Health Organization (WHO) points out that there is no such thing as “low-risk” alcohol consumption, since even low alcohol consumption contributes to alcohol-related physical illnesses (25). In this article, we use the term “low-risk consumption” solely for the purpose of consistency with the terminology used in previous ESA survey waves.

Cannabis

Cannabis is the most commonly used recreational drug after alcohol and tobacco. Some European countries have reported a rise in the prevalence of cannabis use in recent years (26), a trend that was also observed in Germany until 2021 (18, 27). In this survey wave, which was carried out in the months after cannabis legalization in Germany, no significant increase was noted (17). One reason for the absence of an increase could be that only a few Cannabis Social Clubs had received a permit in the early period immediately after legalization. While the use of home-grown cannabis was permitted, it may have been almost unavailable due to the duration of the vegetation period until flowering. Overall, it may have been too early to identify any obvious effects of the change in the legality of cannabis.

Illegal drugs

In previous surveys, cannabis was the most commonly used illegal drug in Germany. In the period covered by the current survey, the substance was no longer classified as an illegal drug. For this reason, the current prevalence of the use of illegal substances (without cannabis) is correspondingly lower compared to previous survey waves (18). Currently, the most commonly used illegal drug is cocaine/crack. Wastewater analyses point to a significant increase in cocaine use and record quantities of cocaine have been seized by police (28). The current findings show no specific increase in cocaine consumption in the last 12 months (18). One explanation for this difference is that surveys representative of the population reflect the proportion of substance users in the total population. In contrast, wastewater analyses capture substance use within a confined geographical area and a limited time period, mainly in individual towns. The quantities of drugs seized by police forces is indicative of the availability and market volume of a substance. Thus, a rise in these indicators could indicate intensified consumption within a stable user group, without any change in the overall prevalence in the population.

Medication

With a 30-day prevalence of daily use of 31.5%, non-opioid analgesics are the most commonly used medication group in Germany. Pharmacy-only over-the-counter analgesics for relief of mild to moderate pain can cause significant side effects if used incorrectly (29, 30). The prevalence is higher in women compared to men. The use of antidepressants is significantly more common in women. Symptoms of depression are more frequently diagnosed and treated in women, while such symptoms are less frequently identified in men (31).

The use of medicinal cannabis was first assessed in 2024. The rate of consumption was 2.7% among the population. About one-third of users (28.7%) consumed medicinal cannabis daily. The proportion of male users was more than double that of women.

Limitations

Survey data on consumption prevalence are subject to bias as a result of various limitations. With a response rate of 22.0%, there is a risk that certain groups may be underrepresented, potentially skewing the results. Self-reported survey data may lead to an underestimation of substance use, because respondents may prefer to answer in a socially acceptable way (32, 33). Contactability by telephone and in writing is not equally guaranteed for all population groups; in particular, persons with a limited command of German, persons without a permanent residence, and persons receiving inpatient treatment may not be covered (34). In addition, studies have shown that persons with low levels of education, low incomes, and poor health are less likely to participate in population-based health surveys (31, 35). Since these characteristics are associated with an increased risk of substance use, this may result in an underestimation of prevalence (35). To assess potential bias introduced by non-response effects, non-participants were asked to complete a short questionnaire on prevalence and/or frequency of use related to five substances (eSupplement).

Conclusion

The use of legal and illegal psychoactive substances remains widespread in Germany. Alcohol is still the most commonly consumed substance, followed by tobacco and non-medicinal cannabis. When taking a patient’s history, substance use in general should be systematically covered. Alcohol is often consumed for many years before dependence develops; in addition, even small quantities can cause harmful effects on health in the long term as well as interactions with medications. By obtaining a focused history, physicians can identify high-risk patients early and offer specific counselling.

Furthermore, the available data point to certain population groups at an elevated risk, enabling a more targeted implementation of preventive measures and counselling in everyday clinical practice.

Given the significant impact of psychoactive substance use on health and society, continual, differentiated monitoring at all levels of medical care is crucial for the early detection of trends and the development and implementation of targeted preventive and interventional measures.

Funding

The 2024 Epidemiological Survey of Substance Abuse (ESA) was funded by the German Federal Ministry of Health (Bundesministerium für Gesundheit, BMG) (funding code: ZMVI1–2520DSM203). The funding is not subject to any conditions.

Conflict of interest statement
EH, SO, JM, and EK received payments for chapters in the yearbook of the German Center for Addiction Issues (Deutsche Hauptstelle für Suchtfragen e. V., DHS).

RH is a paid statistics consultant for university-based research projects—with no direct relation to addition research—and member of the self-help group Kreuzbund e.V.

JM is currently working at the German Federal Statistical Office (Destatis).

SO is Principal Investigator (PI) for the German part of the European School Survey Project on Alcohol and Other Drugs (ESPAD). She led the German data collection of the European Web Survey on Drugs (EWSD) and is a member of the German Psychological Society.

SO and EH are PIs of the German part of the International Cannabis Policy Study (ICPS).

EH received fees for hosting CANDIS workshops and for the manual CANDIS: A Marijuana Treatment Program for Youth and Adults. She is the president of the German Society for Addiction Research and Addiction Therapy (Deutsche Gesellschaft für Suchtforschung und Suchttherapie, DG-Sucht), a member of the Editorial Board of Addiction and Sucht as well as a member of the Hetzler Foundation’s Advisory Board.

JM received fees for presentations atthe Saxony–Anhalt branch of the League for Charitable Care, the Saxony–Anhalt State Office for Addiction Issues, and the Bavarian State Medical Association (BLÄK).

EK is a member of DG-Sucht.

Manuscript received on 16 May 2025, revised version accepted on 29 August 2025

Translated from the original German by Ralf Thoene, M.D.

Corresponding author
Dr. phil. Sally Olderbak

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