Tobacco addiction in Germany: every twelfth working person affected

Whether dismissed as a lifestyle problem and consequently trivialized or cast in a worrying light with a focus on increased sick leave, tobacco addiction in Germany appears to be a serious problem. According to data from the Commercial Health Insurance Fund, the number of outpatient treatments for tobacco addiction among working people in Germany is on the rise. In this article, you can find out when it is considered as an addiction, what the risks of tobacco addiction are and how the perception of it as a "lifestyle problem" threatens to blur the actual problem. You can also read about the opportunities that tobacco-free nicotine pouches can offer here.

KKH data analysis on tobacco addiction among working people in Germany

The Kaufmännische Krankenkasse (KKH), one of the largest statutory health insurance companies in Germany, recently analyzed anonymized data on "tobacco addiction" (according to ICD-10, F17) for the years 2012, 2019 and 2022. The data of around 675,300 compulsorily and voluntarily insured working KKH members with sickness benefit entitlement were used - regardless of the form in which tobacco was consumed, although tobacco cigarettes appear to characterize the majority of all forms of consumption. The results of the evaluation now shed light on an addiction that is often not taken seriously enough by society, urging active efforts to raise awareness.

Comparison of tobacco addiction among single parts of Germany

81 out of 1000 working KKH members entitled to sickness benefit in Germany in 2022 are said to be addicted to tobacco, according to KKH data, withdrawal symptomsacute tobacco intoxication or psychological problems caused by tobacco. And a look at the past few years shows a worrying upward trend here. In 2012, for example, the figure was 50 out of 1000 - an increase of 62 percent in ten years.

In a comparison of the federal states (data records from 2022), the highest number of tobacco addicted professionals are in Mecklenburg-Western Pomerania - specifically, according to the health insurance fund, around 10 percent of those recorded there are affected by an addiction. In Hesse, on the other hand, the KKH records the fewest cases of tobacco use requiring treatment among working people, at 67 per 1,000.

The smoking break - annoying work interruption or "efficiency driver"?

Employers have divergent opinions about smoking breaks. Many believe that numerous interruptions to work result in lower work performance, whereas others see positive aspects. For example, the (smoking) breaks could have an inspiring effect and enable possible increases in efficiency during the work performed.

Michael Falkenstein, an expert on addiction issues at the KKH, would nevertheless like to emphasize the health aspects at this point and sees this as the essence of what it should really be about:

"Bereits ab einer Zigarette am Tag gefährden Raucherinnen und Raucher ihre Gesundheit."

With every additional cigarette, the risk of psychological addiction, respiratory and cardiovascular diseases and cancer increases significantly, and e-cigarettes are also an addictive substance with a risk, says Falkenstein. According to the KKH expert, these also contain dangerous substances that can lead to serious illnesses.

Whether e-cigarettes ultimately pose the same health risks as tobacco cigarettes could at least be questioned at this point. And if the risks were lower, then e-cigarettes could perhaps be seen as an opportunity, as they are in the sense of a strategy of harm minimization through less harmful alternatives.

>> You can read about how the topic of harm reduction can be combined with the EU cancer control plan in: Tobacco Directive in the new EU Commission: The future for Snus and nicotine pouches

Does excessive tobacco consumption increase sick leave?

The fact that excessive smokers pose a certain risk to companies and colleagues could at least be suggested by further figures collected by the KKH in 2023. According to the health insurance fund, the national average number of days of absence last year for employees with excessive tobacco consumption was 21,4 days (much higher than for non-smokers). This is also the highest figure in the past five years and a sharp increase of 55% compared to the previous year 2022 (13,8 days).

How such figures are actually to be interpreted, however, and whether the absences - because they are associated with a diagnosis - can actually be interpreted as "monocausal", could at least be questioned, although it is obvious that comorbidities (concomitant illnesses in addition to those classified as F17) in smokers can be attributed to their tobacco abuse.

Is tobacco addiction a lifestyle problem?

Dismissing an addiction as a "lifestyle problem" probably sounds less dramatic than seeing it as a serious illness. In any case, it seems more harmless to see a bad habit than to focus on the problem of addiction - at least when it comes to linking enjoyment with possible (health) problems in order to ultimately have to curb consumption behavior.

And it is precisely from this that social trivialization draws its strength. Falkenstein knows this:

"Viele Betroffenen verharmlosen das Rauchen auch als schlechte Angewohnheit, die man jederzeit wieder aufgeben kann. Sie werden sich ihrer Sucht viel zu spät bewusst und suchen somit auch erst spät Hilfe."

Anyone who has already fallen into tobacco addiction will realize that giving up smoking is not as easy as initially assumed. But when does the addiction begin and where does the "harmless" enjoyment end?

Criteria for tobacco addiction

The DSM-IV and ICD-10 coding systems are two common international classification systems that can be used to define and classify addictions. With regard to tobacco addiction, both provide a list of criteria that can be used to clearly differentiate an addiction from mere indulgence.

ICD-10 states that if at least three of the following criteria have occurred simultaneously for at least one month, a tobacco addiction can be diagnosed:

• Decreased control over tobacco use; unsuccessful attempt/persistent desire to reduce/control use
• Physical withdrawal syndrome when reducing or stopping tobacco use
• Tolerance development
• Neglect of interests or pleasures in favor of tobacco consumption
• Continued use despite harmful consequences*

Accordingly, the DSM-IV also specifies similar criteria for the diagnostic determination, whereby at least three of the following criteria must be present for the same 12-month period:

• Nicotine use is necessary to avoid withdrawal symptoms
• Substance is taken in larger quantities or over a longer period than originally intended
• Desire or unsuccessful attempts to reduce or control substance use
• A lot of time spent obtaining substances, using substances or recovering from substance effects
• Substance misuse leads to withdrawal from social, occupational and leisure activities
• Substance use continues even though it is recognized that it is mentally or physically harmful*

Withdrawal symptoms can range from dysphoria (irritable mood) to inner restlessness, anxiety and concentration difficulties to insomnia (sleeplessness/disorder) or even serious physical symptoms. In any case, there is a clinically relevant level of suffering and a certain degree of impairment for those affected, which favors the so-called craving (intense desire for tobacco or addictive pressure).

*Source: https://www.apotheken-raucherberatung.ch/raucherberatung-in-der-apotheke-startseite-de/rauchstopp/raucherberatung/klassifikation-der-tabakabhaengigkeit ; The lists of criteria given serve merely as a guide to draw a clearer line between enjoyment and tobacco addiction. Since the medical diagnosis is extremely complex and the above-mentioned criteria have been greatly simplified and should be placed in their exact context, an accurate diagnosis is by no means possible. If this is the case, a licensed specialist is required.

Tobacco addiction according to ICD-10 - the F17 diagnosis

Can tobacco addiction still be considered a lifestyle problem? At least the World Health Organization (WHO) explicitly and clearly identifies tobacco addiction in its medical classification list of diseases and related health problems, the so-called ICD-10, with the diagnosis code "F17" as "Mental and behavioural disorders due to tobacco", leaving little room for trivialization*.

If one finally delves deeper into the F17 diagnosis, possible pernicious problems of tobacco abuse/withdrawal become immediately clear. In particular, its excesses in serious pathological manifestations - from withdrawal syndrome (F17.3) (with delirium - F17.4) to psychotic disorder (F17.5), for example.*1

*Cf. also: https://klassifikationen.bfarm.de/icd-10-gm/kode-suche/htmlgm2024/block-f10-f19.htm

*1 See also: https://www.icd-code.de/icd/code/F17.-.html 

KKH-addiction-expert emphasizes effectiveness of smoke stop even for over 60s

Quitting is worthwhile in any case - Falkenstein is keen to emphasize that it makes sense to give up smoking even after the age of 60:

"Viele glauben es nicht, aber Aufhören lohnt sich in jedem Alter. Selbst wer erst als über 60-Jähriger auf Zigaretten verzichtet, senkt das Risiko für Herz-Kreislauf-Erkrankungen bereits innerhalb weniger Jahre erheblich."

For employees, the expert recommends observing addiction problems among colleagues and, if necessary, contacting the next-highest manager or the company doctor: „Keinesfalls sollten problematischer Konsum gedeckt und die Auswirkungen durch andere ausgeglichen werden müssen“, says Falkenstein.

There are many different support programs in Germany to promote the health of companies. The KKH also offers a contact point that has been set up specifically for the topic of addiction in the workplace. Those affected can also find a service with an individual prevention program for smoking cessation at: https://www.kkh.de/leistungen/praevention-vorsorge/suchtpraevention/nichtraucherhelden

Nicotine pouches as an enabler for smoke stop

Nicotine pouches certainly also contain nicotine, a substance that can be highly addictive. One could therefore conclude that such alternatives to cigarettes would merely shift addictive behavior from one form of consumption to another. Of course, this is not entirely wrong - and such a form of consumption also requires a certain degree of awareness of the aforementioned addictive potential.

But firstly, nicotine pouches are tobacco-free and various health problems associated with tobacco can be avoided by switching. First and foremost, carcinogenic tobacco-specific nitrosamines (TSNA), which are not contained in the white pouches, are considered avoidable. It would therefore be possible to significantly avoid the cancer risk that cannot be denied for products containing tobacco.

Secondly, smoking places a considerable burden on the lungs and increases the risk of a variety of respiratory diseases. Such risks can be avoided by consuming nicotine orally.

And if nicotine pouch consumption is kept in moderation or is done with the intention of escaping a tobacco addiction - ideally with professional support from various institutions - it may be possible to get a really harmful vice under control with its help and ultimately master tobacco/smoking cessation.

In line with the facts, it must be pointed out at this point that there are some nicotine replacement products that have already been used successfully in nicotine replacement therapies for some time. However, it is the variety of options that is most likely to produce successful recipes. For example, new types of nicotine pouches with Nicotine Polacrilex an extremely interesting, alternative form of application that may encourage even more tobacco users to quit and give them a smoke-free future future.

You can read about how tobacco-free nicotine pouches can actually support smokers who want to quit in practice in: Nicotine pouches as a cigarette alternative - education could promote smoking cessation