Germany’s comparatively high smoking rate shows that cessation-only policies are insufficient to end cigarettes.
By Stefanie Rossel
Germans, it appears from anecdotal experience, are a stubborn species when it comes to smoking cessation. During a recent holiday at the French Riviera, we had a heavily smoking couple from the Lower Rhine as neighbors at our resort. Out of professional interest, I asked them whether they had ever tried to quit. The husband showed me a scary-looking scar on the side of his ribcage and said, yes, he had stopped for two years after his surgery but then relapsed to smoking what looked like at least a pack per day. Quitting again was clearly not on his agenda nor on his wife’s. At the mention of less hazardous alternatives to combustible cigarettes, they gave me a skeptical look.
That smokers like these are the rule rather than an exception confirms a survey commissioned by Philip Morris Germany (PMG) that looked at the barriers to quitting. Carried out first in 2021 and updated in 2022, the research found that last year, 51.3 percent of the 1,000 participating German adult smokers representing all age groups, genders and federal states did not want to give up smoking—only slightly less than in the first edition of the study (53.5 percent).
The German Survey on Smoking Behavior (DEBRA), a bi-monthly representative, face-to-face household survey on the use of tobacco and alternative nicotine-delivery systems (ANDS) conducted by Heinrich Heine University Duesseldorf, measured an even lower motivation to quit smoking in Germany, relates Alexander Nussbaum, head of scientific and medical affairs at PMG. “Almost three-quarters of the nearly 19,000 smokers surveyed did not express the intention to quit smoking,” he said. “Our own survey from 2022 confirms what we already measured in 2021: More than half of German smokers do not currently express the intention to quit smoking. Even those who are motivated to quit smoking are rarely specific in their plans: Only 3 percent to 5 percent of them plan to quit in the next month.”
At 64.4 percent, it’s particularly smokers over 65 years who are uninterested in stopping. In addition, the PMG study found, every third smoker over 50 years of age has never seriously tried to quit. There’s a pronounced correlation between motivation and actual quitting attempts; 76.4 percent of smokers who never tried to stop smoking were also unmotivated to quit.
Motivation for smoking cessation also varied between socioeconomic groups: 64.5 percent of participants in the lowest income group said they had no intention to quit whereas in the highest income group, the figure was 43 percent. “Even among smokers with the highest educational level in our survey—‘college, university without/with degree’—almost half were not motivated to quit smoking in 2021,” said Nussbaum. “However, this proportion increased to 61 percent for smokers with the lowest educational level—i.e., ‘elementary school with/without completed apprenticeship.’ The motivation to stop smoking is not solely dependent on education. Rather, our results from 2022 show a strong correlation with income.”
Beyond Smokers’ Reality of Life
Depending on the sources, between 23 percent and 34 percent—that is, between 17 million and 18.9 million of the more than 83 million Germans—currently smoke. Smoking prevalence in the country is significantly higher than in other European nations. Germany, which ratified the World Health Organization’s Framework Convention on Tobacco Control (FCTC) in 2005, has repeatedly been criticized for being too lax in implementing tobacco control measures, most recently by Ruediger Krech, the WHO director for health promotion. On the occasion of the publication of the ninth WHO Report on the Global Tobacco Epidemic on July 31, 2023, Krech noted that the country’s ban on indoor smoking was inconsistent, advertisements against the harmful effects of smoking in public spaces were poorly enforced and inflation had little impact on the affordability of tobacco products.
Whether higher prices or expanded smoking bans would significantly reduce prevalence is questionable when looking at the reasons people named for continuing to smoke, however. According to PMG’s survey, 50.1 percent of participants stated that they enjoy smoking, making this the biggest barrier to smoking cessation. That share was particularly high among older smokers (58 percent) and those with no motivation to quit (62 percent). More than half of the people surveyed had been smoking for more than 20 years, making habits and learned behavior another major barrier to quitting smoking. “Lack of discipline” was quoted as a further hindrance. Only 12 percent named “cost” (of offers or products to support quitting cigarette smoking) as keeping them from stopping smoking.
It’s not that there weren’t any smoking cessation programs or initiatives available. Since 2014, for example, the S3 guideline, “Smoking and tobacco dependence: screening, diagnosis and treatment,” has provided healthcare professionals with recommendations on how to help smokers quit. S3 means that the guideline has undergone all elements of a systemic development, including decision and outcome analysis and assessment of the clinical relevance of scientific studies. The recommendations of the current S3 guideline include low-threshold tools such as short motivational counseling and envisage nicotine-replacement therapy (NRT) only as a last measure after education and psychotherapeutic support. The guideline advises explicitly against using e-cigarettes as a smoking cessation aid.
“A medical smoking cessation guideline is primarily effective among smokers who are already motivated to stop smoking and who seek advice from their family doctor or pharmacist on how they can completely give up tobacco and nicotine, which is always the best option,” says Nussbaum. “However, it is also a fact that the majority of smokers in Germany are currently not motivated to quit smoking, and this is reflected in the stable or even increasing smoking rate. This in turn suggests that the measures taken to date, including the smoking cessation guideline, are missing the needs of the majority of smokers.”
This is also evident from the fact that e-cigarettes are now used by 10 percent of smokers to wean themselves off of cigarette smoking, according to the DEBRA study. This makes vapor products the most frequently used form of cessation support in Germany, despite the fact that they are not recommended in the guideline and despite the prevailing misperceptions about comparative health risks. According to a survey by the German Federal Institute for Risk Assessment (BfR), 63.3 percent of smokers consider e-cigarettes to be at least as risky as combustible cigarettes.
“The results [of the PMG survey] clearly show that the best measures, such as the gold standard of NRT and behavioral therapy recommended in the medical smoking cessation guideline, are of little use if they do not reach the smokers’ reality of life, for instance, because the motivation to stop smoking is lacking,” says Nussbaum. “That said, alternative nicotine products, such as e-cigarettes, heated-tobacco products or nicotine pouches, are not cessation tools but rather consumer products for adult smokers who for whatever reason are not quitting cigarette smoking.”
Wanted: Clear Communication
Nussbaum calls for support of measures that promote complete smoking cessation. “This includes education among medical professionals and their adequate remuneration, e.g., by health insurances, for smoking cessation treatment as well as low-threshold access to therapeutics,” he says.
For adult smokers who would otherwise continue to smoke, alternative noncombusted nicotine products could better address their barriers and significantly reduce exposure to harmful substances from cigarette smoke as intended by the concept of harm reduction, he adds. The German government, he insists, should invest more in education campaigns to help smokers properly assess the relative risks of cigarettes versus noncombusted alternatives and make better choices than continued smoking if they do not quit nicotine use altogether.
Nussbaum calls for a clear, unambiguous education. “For example, as in the U.K., simple-worded flyers that say: ‘The harmfulness of cigarette smoking is primarily related to the toxicants from tobacco combustion’ and: ‘Alternative nicotine products such as e-cigarettes, heated-tobacco products, or nicotine pouches are not risk-free and still contain the addictive nicotine, but, for all we know today, have considerably less potential for harm than cigarettes,’” he says.
The sole focus on the protection of young people is obviously not having the intended effect, notes Nussbaum. On the contrary, according to the DEBRA study, cigarette smoking—by far the most harmful form of nicotine consumption—is currently rising among young people while the smoking rate among adults continues to stagnate.
“I believe that all stakeholders in the healthcare system who are interested in differentiated risk communication have a responsibility, including the Federal Drug Commissioner and authorities such as the Federal Center for Health Education and the BfR,” he says. “The same applies to medical societies and health insurance companies—many of which, however, have not treated smoking, smoking cessation and the scientific evidence for harm reduction with the necessary focus.”
For its study update, PMG also surveyed former smokers who had switched to e-cigarettes or tobacco-heating products. Interestingly, they cited similar barriers to quitting smoking in retrospect. “What surprised us: Many aspects, such as ‘enjoy smoking,’ ‘can’t see it through’ or ‘don’t want to cut down,’ were even more pronounced in this sample in retrospect than among current smokers,” said Nussbaum.
“Nevertheless, they have managed to abandon cigarette smoking. We are currently investigating whether the level of information about alternative nicotine products was decisive for the switch. Overall, this shows us: Alternative nicotine products without tobacco combustion have the potential to open a pathway away from the by far most harmful form of nicotine use, cigarette smoking, for a large group of smokers with no motivation to stop smoking and with barriers such as ‘I enjoy smoking.’” Due to misperception, this potential remains largely unused, according to Nussbaum.
U.K. Leads the Way
To reach this base of smokers unwilling to quit, both manufacturers and regulators have a responsibility, stresses Nussbaum. “Alternatives developed by the industry must […] address the needs of the many smokers who are not motivated to quit smoking,” he says. “In addition to the development of alternative products, their regulation in comparison with cigarettes regarding tax/price, communication options, product testing in specialist shops, etc., plays a decisive role in ensuring that they are attractive to adult smokers who would otherwise continue to smoke, without attracting nonsmokers. To achieve the ideal solution of quitting all tobacco and nicotine products, NRTs remain a valid option, especially for motivated smokers willing to use them. NRTs are most effective when used in combination with behavioral therapy or adjunctive support.”
Nussbaum points to the U.K. as an example for Germany to follow in its efforts to reduce smoking prevalence. “Alternative nicotine products are an important pillar in the strategy to curb cigarette smoking in the U.K., which is part of the FCTC. Remarkably, this is in line with the FCTC, which lists ‘harm reduction’ as one of several pillars of tobacco control,” he says.
“At the same time, the U.K. applies a very strict regulatory framework around cigarettes. It is precisely this differentiation based on the scientifically supported differences between nicotine products—the ‘risk continuum’—that seems to account for the success of the British approach. The consequence is a very low smoking rate by international standards of just over 10 percent.”
The U.K.’s success has also been bolstered by differentiated risk communications about alternative nicotine products and cigarettes through easily understandable messages such as “Clearing up some myths around e-cigarettes” by the U.K. Health Security Agency or the recently published fact sheet “Addressing common myths about vaping” by the U.K. public health charity Action on Smoking and Health (ASH).
“One looks in vain for something like this from German health authorities,” laments Nussbaum.