Waterpipe use in Germany (2018 - 2024): Prevalence and sociodemographic differences in age of initiation

Waterpipe (WP) use poses not only a risk of nicotine dependence but also additional health hazards. This study examined trends in WP use in Germany, focusing on prevalence by age group and differences in initiation age.

We analysed data from 76,239 respondents (≥ 14 years) from the German Study on Tobacco Use (DEBRA); a series of bi-monthly national surveys using face-to-face interviews at home (2018 - 2024). Prevalence trends were modelled using binomial logistic regression models with restricted cubic splines.

The prevalence of WP use decreased over time, to an estimated 0.9 % (95 % CI = 0.6 - 1.2) by mid-2024. This prevalence is made up of 0.1 % (95 % CI = 0.0 - 0.2) 14- to 17-year-olds, 0.3 % (95 % CI = 0.2 - 0.6) 18- to 24-year-olds, 0.3 % (95 % CI = 0.2. - 0.4) 25- to 39-year-olds, and 0.2 % (95 % CI = 0.1 - 0.3) people aged 40 years and older. WP use increased until 2020 up to 2.8 % (95 % CI = 2.3 - 3.4), remained stable for two years and then decreased, especially among people between 25 and 39 years of age. The proportion of 14- to 17-year-old users and users aged at least 40 years remained stable over the years at a low level. Median initiation age was 18 years (25th percentile: 16 years; 75th percentile: 22 years). A lower initiation age was associated with male gender and lower income.

WP use increased from 2018 - 2020, stabilised from 2020 - 2022, and then decreased until 2024. Median initiation age was 18, with males and people with lower income starting at a younger age. Targeted public health interventions, focusing on younger males and those with lower socioeconomic status, are needed to prevent early use.