How prevalent is smoking and nicotine dependence in primary care in Germany?

Identifying, diagnosing and reducing nicotine use, dependence and related morbidity are considered key responsibilities of primary care physicians. Little is known, however, about the magnitude of the problem in primary care and the extent of treatment in Germany. This paper reports on (1) life-time and point prevalences of smoking and nicotine dependence among unselected consecutive German primary care attendees; (2) associations of smoking status with socio-demographic features and (3) rates of doctors' recognition and treatment patterns.

Data came from the Smoking and Nicotine Dependence Awareness and Screening Study (SNICAS), a nationally representative two-stage epidemiological point prevalence study (stage I: prestudy characterization of a nation-wide sample of 889 primary care doctors; stage II: target day assessment of 28,707 unselected consecutive patients).

(1) Of all primary care attendees, 71% reported having ever used a tobacco product (life-time regular smokers 51%; life-time occasional smokers 21.5%.). Point prevalence (4 weeks) of smoking was considerably lower (occasional use 4.7%, regular use 24.9%). The rate of DSM-IV nicotine dependence (13.9%) was highest among the youngest age groups. (2) Rates of regular and dependent smokers decreased markedly with age, mainly as a result of the steadily increasing numbers of male ex-smokers and low numbers of older female life-time ever smokers. Young age, unemployment, being single, divorced, widowed or separated from the partner were associated with higher rates of smoking or nicotine dependence. (3) In about 25% of patients, primary care doctors failed to recognize the patient's current smoking and/or nicotine dependence. Case recognition was highest for nicotine dependence (76%). Among recognized cases, 56% had ever received any kind of advice or counselling about quitting; yet only 12% had ever participated in any smoking cessation programme.

Beyond the confirmation of the well-established finding of a high prevalence of smokers in primary care, this paper demonstrates (1) considerable point prevalence of DSM-IV nicotine dependence (14%); (2) that it is noteworthy, however, that the rates are not higher than those in community samples; and (3) a considerable variation by age group with highest rates among the young (22-31%), but considerably lower rates among subjects aged 50 and above (16% to 0.9% in the oldest). This substantial association with age seems to be due mainly to the low smoking rates in older women and the increasing numbers of successful, particularly male, quitters from 40 years onwards. Recognition of primary care patients' smoking status by primary-care practitioners was moderate, and the frequency of past and current primary care interventions was low. These findings call for systematic investigation into barriers that impede the implementation of smoking cessation interventions in primary care settings.