Problematic Consumption of Alcohol, Cannabis and Cigarettes

A German Nationwide Survey on Psychopathology, Stress, Mindfulness, and Quality of Life

Background: Even among minors, the use of psychotropic substances is widespread in Europe. Data on the use of tobacco, alcohol and cannabis are regularly reported in Germany, but data on problematic use are lacking. In the present study, established screening instruments were used to investigate the prevalence of problematic use of cigarettes, alcohol and cannabis among children and adolescents.

Methods: A survey that was designed to be representative was conducted across Germany in a sample of 4001 persons aged 12–17. The survey consisted of established screening instruments for problematic consumption patterns and related psychosocial aspects. Prevalences were estimated, and bivariate and multivariate associated characteristics were studied.

Results: Among 12- to 17-year-olds in Germany, the prevalence values (with 95% confidence intervals) of problematic use were: for cigarettes, 0.5% [0.3; 0.7]; for alcohol, 11.3% [10.3; 12.3]; and for cannabis, 0.5% [0.3; 0.7]. For the problematic use of cigarettes, alcohol and cannabis, there were both bivariate and multivariate statistically significant associations with greater psychopathology, lower mindfulness, and a lower quality of life. For example, greater psychopathology and stress experience were both associated with an increased risk of problematic cannabis use (odds ratios 1.21 [1.11; 1.31] and 1.59 [1.33; 1.88]).

Conclusion: A comparison with the few available previous findings implies that problematic alcohol consumption has become more prevalent. There were both similarities and differences across the three substances studied with respect to patterns of problematic consumption, particularly in relation to the experience of stress.

Even among minors, the use of psychotropic substances is widespread in Europe, as shown by the findings of the European School Survey Project on Alcohol and Other Drugs (ESPAD [1]). For Germany, the Federal Centre for Health Education (BZgA) regularly reports in its “Alcohol Surveys” on the use of tobacco, alcohol, cannabis, and illegal drugs among 12– to 25-year-olds (2). Epidemiological studies of adults, such as the German Health Interview and Examination Survey for Adults (3), use additional screening instruments such as the alcohol use disorders identification test for consumption (AUDIT-C) (4) to identify patterns of problematic consumption. These tools have not been used in BZgA alcohol surveys to date. However, problematic substance use in adolescence is of great importance with regard to the risk of chronification of the behavior pattern into adulthood (5). According to Rauschert et al. (6), problematic use of a substance may be “[...] indicating dependence.”

The German clinical practice guidelines “Smoking and Tobacco Dependence: Screening, Diagnosis, and Treatment” (7) and “Screening, Diagnosis, and Treatment of Alcohol Use Disorders” (8), which also include children and adolescents, both expressly recommend the use of a screening instrument for diagnostic purposes:

• For tobacco use: the Fagerström test for cigarette dependence (FTCD) (9)
• For alcohol use: the Alcohol Use Disorders Identification Test (AUDIT) (10).

In the last Epidemiological Survey on Substance Abuse, a regular survey of 18- to 64-year-olds in Germany, the AUDIT, for example, was also used (6). For children and adolescents, there are hitherto no data from representative German samples on problematic consumption patterns collected using these screening instruments. Previous findings are generally only available for alcohol, assessed using the AUDIT-C (11); as yet, there are no such findings for cigarettes or cannabis.

The aim of this study was to determine, using established screening instruments, the prevalence of problematic use of cigarettes, alcohol, and cannabis in a sample of children and adolescents designed for representativeness. In addition, the associations with psychopathology, stress experience, mindfulness, and quality of life were investigated.

Methods

Data collection

The data for the multi-stage random sample of 12- to 17-year-olds in this study were collected by telephone by an established institute of market and opinion research (Forsa) (weighted combined landline and cell phone sample, known as a dual-frame design according to the standard of the the German Business Association for Market and Social Research [Arbeitskreis Deutscher Markt- und Sozialforschungsinstitute e. V., ADM]). Computer-assisted telephone interviews (CATI method, for example [12]) were conducted with a total of 4,001 participants. The response rate (telephone interview completed) was 35.0% of the net sample. In all, 35.2% of individuals declined to participate, 25.2% could not be reached, and 4.6% discontinued the interview. The telephone interview lasted on average just under 18 min. To achieve representativeness for the 12- to 17-year-old age group in Germany, the sample was weighted once data collection was complete according to the following characteristics: sex, year of birth, and region. This was carried out on the basis of the population projections of the German Federal Statistical Office (Statistisches Bundesamt) (as of: 31.12.2019).

The scientific design of the study, the statistical analyses, and the processing of the data collected were undertaken entirely by the authors. The processes required in order to recruit the participants, obtain their informed consent, and gather the data were approved in advance by the local psychological ethics committee at the Center for Psychosocial Medicine of the University Medical Center Hamburg-Eppendorf (LPEK-0196). The IMAC-Mind project was carried out from 01.11.2017 to 31.12.2023.

Investigation methods

Problematic cigarette use was assessed using the FTCD (formerly: Fagerström Test for Nicotine Dependence, FTND) (13). The FTCD, using six items (with alternating yes/no and multiple-choice questions), makes it possible to assess the intensity of cigarette dependence (7). The six responses are summed up to yield a total score, with a higher score indicating more intense cigarette dependence. Since there are no empirically based specific cut-off values for minors, threshold values were taken from a published prevalence study conducted in India in which the FTND was used on adolescents (14). Accordingly, scores ≥ 4 were interpreted as an indication of a medium level of dependence, while scores ≥ 6 were considered an indication of a high level of cigarette dependence (14). Since even moderate dependence on cigarettes can be considered problematic in children and adolescents, this differentiation was dispensed with in the present study. We assumed problematic cigarette consumption from a cut-off value of ≥ 4 points (for example, [15]).

Problematic consumption of alcohol in the previous 12 months was assessed using the AUDIT with altogether 10 items. The response format of the screening instrument is not consistent: two questions have three possible answers and eight items have five possible answers. A total score can be calculated from the 10 questions, with a higher score pointing to a higher degree of problematic alcohol consumption. According to the German clinical practice guideline “Screening, Diagnosis, and Treatment of Alcohol Use Disorders” (16), a cut-off value of 6 or 7 points appears to be appropriate for adolescents in the AUDIT. Based on this recommendation, problematic alcohol consumption was assumed at 6 or 7 points in the AUDIT (both prevalence estimates are reported in the Results section). However, for both the further statistical analyses and the interpretation of the findings, the more conservative estimate based on a cut-off value of 7 points was used.

Problematic cannabis use in the previous 12 months was assessed using the Cannabis Abuse Screening Test (CAST) (17). The CAST consists of six questions with five possible answers (0 = “never,” 1 = “rarely,” 2 = “from time to time,” 3 = “quite often,” 4 = “very often”). For each item there is a threshold value at which dichotomization takes place, and a total score is calculated based on this. According to Piontek et al. (18), a total score of ≥ 4 points can be used as an indicator of problematic cannabis consumptions.

Psychopathology in the previous 6 months was assessed using the Strengths and Difficulties Questionnaire (SDQ) (19). The SDQ includes 25 items, each with three possible answers (0 = “Not true,” 1 = “Somewhat true,” 2 = “Certainly true”). From this, four problem scales (“Emotional symptoms,” “Conduct problems,” “Hyperactivity,” and “Peer relationship problems”) can be formed as well one scale that assesses the resource “Prosocial behavior” (20). The four problem scales can be used to calculate a total score that is considered a good indicator of (overall) psychopathology (21). The higher the total SDQ score, the greater the psychopathology.

Stress perceptions in the previous 30 days were investigated using the Short Form Perceived Stress Scale (PSS-4 short form) (22). The PSS-4 short form comprises four items each with five possible answers (0 = “Never,” 1 = “Almost never,” 2 = “Sometimes,” 3 = “Fairly often,” 4 = “Very often”). A total score can be calculated from the four answers, with a higher score pointing to a higher degree of perceived stress (23).

The mindfulness parameter was investigated using the Mindful Attention and Awareness Scale for Adolescents (MAAS-A) (24). When developing the MAAS instrument “…the aspect of focusing mindfulness on the present moment was priorized” (25). The MAAS-A consists of 15 items with six possible answers (1 = “Almost always,” 2 = “Very frequently,” 3 = “Somewhat frequently,” 4 = “Somewhat infrequently,” 5 = “Very infrequently,” 6 = “Almost never”) (25). An average is determined across all questions, and the higher this is, the greater the level of mindfulness.

Health-related quality of life in previous weeks was assessed using the KIDSCREEN-10 Index (26). KIDSCREEN-10 comprises 10 questions (with an alternating, five-possible-answer format). The index can be interpreted as a global measure of health-related quality of life (27), with higher scores indicating better quality of life. In addition, key sociodemographic characteristics (e.g., sex, year of birth, and migration background of the children and adolescents) were surveyed.

Data analysis

To estimate the prevalence of problematic use of cigarettes, alcohol, and cannabis among children and adolescents, relative frequencies were calculated with 95% confidence intervals (95% CI). Two respondents (0.05% of the total sample) stated “diverse” for gender. Since it is not possible to make statistically reliable statements for a group comprising two cases, these two cases were not included in the further statistical evaluations. A total of 3398 adolescents reported that they had never smoked cigarettes. For these individuals, a total score of 0 was used in the FTCD for the further calculations. Similarly, the total score in the AUDIT was set to 0 for the 2296 individuals who did not consume alcohol and the total score in the CAST was set to 0 for the 3653 individuals who did not use cannabis. Associations between the three dependent variables (problematic consumption of cigarettes, alcohol, or cannabis) and the independent variables (psychopathology, stress experience, mindfulness, and quality of life) were investigated using bivariate logistic regressions. In additional multivariable analyses (likewise using logistic regressions), these associations were adjusted for sex, year of birth, and migration background. For the independent variables, means and standard deviations were additionally calculated. All analyses were performed using SPSS statistical software (version 27.0).

Results

The sample consisted of 4001 children and adolescents in Germany aged between 12 and 17 years. When asked about gender, 1940 individuals (48.5% of the total sample) identified as girls and 2059 (51.5%) as boys (“diverse” was also stated twice). In total, 21.5% of individuals reported having a migration background. The majority of respondents (93.0%) still attended school (approximately four out of five of these individuals were in grades 5–10 and the rest in grades 11–13). A further 6.9% of respondents were currently no longer attending school (most of these were undertaking vocational training), while data on this characteristic were lacking for 0.1% of the sample. The degree of psychopathology, stress experience, mindfulness, and quality of life in the sample as a whole is presented in Table 1. The prevalence estimates for non-problematic and problematic use of cigarettes, alcohol, and cannabis among children and adolescents can be found in Table 2. In each case, there were no sex differences.

Table 1

Means and standard deviations for the overall sample for: psychopathology, stress experience, mindfulness, and quality of life

Table 2

Prevalence estimates for non-problematic and problematic consumption of cigarettes, alcohol, and cannabis

The bivariate regression analyses showed statistically significant associations between problematic use of cigarettes, alcohol, and cannabis with greater psychopathology, lower mindfulness, and lower quality of life (Table 3). In the bivariate analyses, however, only problematic cannabis consumption was associated with greater stress experience (Table 3).

Table 3

Bivariate associations of psychopathology, stress experience, mindfulness, and quality of life with problematic cigarette, alcohol, and cannabis consumption (logistic regression analyses)

When the effect of sex, year of birth, and migration background was taken into account, (multivariable) logistic regression analyses continued to show associations between problematic use of cigarettes, alcohol, and cannabis in each case and higher psychopathology, lower mindfulness, and lower quality of life (Table 4). Problematic consumption of alcohol as well as of cannabis was associated with greater stress experience among children and adolescents in these analyses (Table 4).

Table 4

Associations of psychopathology, stress, mindfulness, and quality of life with problematic cigarette, alcohol, and cannabis consumption, each adjusted for sex, age, and migration background (logistic regression analyses)

Discussion

The aim of this study was to investigate the prevalences of problematic consumption of cigarettes, alcohol, and cannabis in the 12- to 17-year-old age group using established screening instruments as well as their associations with psychopathology, stress experience, mindfulness, and quality of life. As already reported, the data from representative samples are very limited for Germany. The available data primarily come from studies conducted by the BZgA; however, they do not include information regarding problematic consumption. There is a previous analysis of problematic alcohol consumption in a representative sample of 12- to 25-year-olds by Wartberg et al. (11), albeit assessed using the AUDIT-C. The AUDIT-C can be extracted from the AUDIT. However, in the present study, the AUDIT-C would also yield a higher prevalence estimate of 8.7% compared to the 5.0% for 12- to 17-year-olds in Wartberg et al. (11). A comparison of the two sets of findings points to an increase in problematic alcohol consumption among 12- to 17-year-olds in Germany since 2016.

In the present study, the prevalence estimate for problematic alcohol consumption of 11.3% (according to AUDIT) is generally significantly higher than the prevalence rates for problematic use of cigarettes and cannabis (0.5% each). According to these prevalence estimates, around one in nine 12- to 17-year-olds in Germany would have problematic alcohol consumption, while one in 200 would have problematic use of cigarettes and cannabis. For the problematic consumption of cigarettes, alcohol, and cannabis, there were no differences in prevalence between boys and girls, as was also observed in Wartberg et al. (11) for problematic alcohol consumption.

Significantly higher prevalence estimates have been reported for German adults. In their sample of 18- to 64-year-olds, Rauschert et al. (6) found problematic use of tobacco in 7.8% of respondents, alcohol in 17.6%, and cannabis in 2.5%. The study conducted by Kotz et al. (28) showed an annual prevalence of cannabis use among 14- to 24-year-olds of 11.4%. Higher prevalence rates among adults may be the result of greater financial resources and potentially more opportunities for consumption. One must also take into account the COVID-19 pandemic, which is likely to have restricted youth’s access more so than that of adults.

Below we discuss the characteristics that were each statistically significantly associated—both in bivariate and multivariate analyses—with problematic consumption, since these findings are considered to be more robust. Uniformly, problematic use of cigarettes, alcohol, and cannabis was associated with higher psychopathology, lower mindfulness (with the highest observed effect sizes), and lower quality of life. There is good empirical evidence for associations with higher psychopathology (for example, [29] for alcohol), but significantly fewer findings are available for mindfulness and quality of life. The finding that a greater level of stress was only associated with problematic use of cannabis, but not cigarettes, is remarkable and novel—it is possible that cannabis use is relevant as a dysfunctional coping strategy for those affected.

Limitations

This study has a number of limitations. It is conceivable that there was a selection bias in the survey. Socially desirable responses regarding substance use cannot be ruled out in an investigation of this kind. This type of response behavior would result in a misclassification bias and potentially underestimate prevalence rates. Urine or hair analyses could be used to objectively verify the self-reported information. An extensive study in the USA found high rates of agreement between self-reported tobacco and cannabis consumption and the findings of urine tests for 12- to 25-year-olds (30). There is no empirical verification of cut-off values for the FTCD in adolescents, and although the instrument has already been used in previous studies in adolescents and found to be psychometrically suitable (31), it is not clear to what extent it is suitable for the estimation of prevalence in 12- to 17-year-olds. The data were collected during the COVID-19 pandemic and it is unclear how stable these findings will remain. Future studies should additionally investigate the trend in problematic consumption of tobacco heaters and e-cigarettes using suitable screening instruments. However, at the time of the survey, daily use of e-cigarettes among 12- to 17-year-olds was still a rare phenomenon in this sample.

Summary

Despite these limitations, some important new findings—in addition to the prevalence estimates—emerged particularly on stress, mindfulness, and quality of life. Whether problematic alcohol consumption among adolescents remains stable at such a high level should be further investigated. The results presented here could be used for the development or modification of primary and secondary preventive approaches (for example, for the school setting) or clinical interventions. Following the recent legalization of cannabis in Germany, the findings of this study provide a baseline that has been collected in advance and can be used to assess future developments.

Funding

The IMAC-Mind project was funded by the German Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung, BMBF; Grant No.: 01GL1745A).

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript received on 3 August 2023, revised version accepted on 21 March 2024.

Translated from the original German by Christine Rye.

Corresponding author
Prof. Dr. phil. Lutz Wartberg
MSH Medical School Hamburg
Fakultät Humanwissenschaften
Department Psychologie
Am Kaiserkai 1
20457 Hamburg, Germany

Cite this as:
Wartberg L, Belau M, Arnaud N, Thomasius R, on behalf of the IMAC Mind Consortium: Problematic consumption of alcohol, cannabis and cigarettes—a German nationwide survey on psychopathology, stress, mindfulness, and quality of life. Dtsch Arztebl Int 2024; 121: 422–7. DOI: 10.3238/arztebl.m2024.0061

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