Can the THC concentration predict the number of patients with cannabis-related diagnoses?

INTRODUCTION: The use of high-potency cannabis products is associated with an increased risk of mental disorders. This study investigates whether the rising THC concentration in Germany is associated with an increase in cannabis-related diagnoses. METHODS: The number of insured persons with at least one cannabis-related ICD-10 F12 diagnosis (e.g., harmful use, dependence) in outpatient care was provided by statutory health insurance funds between 2009 and 2021. The dependent variable is the ratio of (a) the number of insured persons with at least one F12 diagnosis to (b) all insured persons who have used cannabis in the last year. Information on THC concentration in cannabis flower was provided by law enforcement agencies. Using generalised mixed linear models, the dependent variable was predicted by the median THC concentration in cannabis flower. RESULTS: The regression results show that an increase in THC concentration by one percentage point is significantly associated with an increase in the proportion of diagnoses (women: +0.17; men: +0.42). THC concentration positively predicted the proportion of diagnoses in all 16 federal states for men and in 15 federal states for women. DISCUSSION AND CONCLUSIONS: Compared to low-potency products, using high-potency products may pose additional health risks, which may be particularly pronounced in men. Acknowledging the limitations of the ecological study design and uncertainties inherent to the analysed data, further investigations on the sex-specific impact of THC exposure are required. Limiting the THC concentration in cannabis products and closely monitoring THC consumption in the population appears necessary.

Alcohol-Specific Inpatient Diagnoses in Germany: A Retrospective Cross-Sectional Analysis of Primary and Secondary Diagnoses from 2012 to 2021.

AIMS: Our study aimed to a) describe the distribution of hospital discharges with primary and secondary alcohol-specific diagnoses by sex and age group, and b) describe how the number of hospital discharges with primary and secondary alcohol-specific diagnoses have changed across different diagnostic groups (categorized by primary International Classification of Diseases, 10th Revision [ICD-10] diagnosis) over time. DESIGN: Retrospective cross-sectional analysis. SETTING: German hospital settings between 2012 and 2021. PARTICIPANTS: All persons aged 15-69 admitted to hospitals as registered in a nationwide data set. MEASUREMENTS: We counted a) the number of all hospital discharges and b) the number of hospital discharges with at least one alcohol-specific secondary diagnosis (secondary alcohol-specific diagnosis) by year, sex, age group, and diagnostic group. One diagnostic group included all primary alcohol-specific diagnoses, while 13 additional groups aligned with ICD-10 chapters (e.g., neoplasms). Alcohol-involvement was defined as either a primary or secondary alcohol-specific diagnosis. FINDINGS: Of 95 417 204 recorded hospital discharges between 2012 and 2021, 3 828 917 discharges (4.0%; 2 913 903 men (6.4%); 915 014 women (1.8%)) involved either a primary or at least one secondary diagnosis related to alcohol. Of all alcohol-involved hospital discharges, 56.8% (1 654 736 discharges) had no primary but only a secondary alcohol-specific diagnosis. Secondary alcohol-specific diagnoses were particularly prevalent in hospital discharges due to injuries. With rising age, alcohol-involvement in hospital discharges due to digestive or cardiovascular diseases increased. Between 2012 and 2021, the rate of alcohol-involved hospital discharges has decreased more in younger as compared with older adults (average change between 2012 and 2021: 15-24: -55%; 25-34: -41%; 35-44: -23%; 45-54: -31%; 55-64: -21%; 65-69: -8%). CONCLUSIONS: The number of alcohol-involved hospital discharges in Germany from 2012 to 2021 more than doubles (from 1 654 736 to 3 828 917) when including secondary alcohol-specific diagnoses. More pronounced declines among younger adults may be attributed to unequal changes in alcohol consumption patterns across the population and to the hazardous effects of long-term alcohol use.

Treatment demand for cannabis use problems: analyses of routine data from 30 European countries.

Cannabis use and treatment demand has risen in the past decade. Previous analyses of treatment demand are limited by methodological constraints or are outdated. Cross-country differences and trends in cannabis treatment demand are described using data from the European Monitoring Centre for Drugs and Drug Addiction. Two novel indicators are employed: firstly, the cannabis-attributable treatment fraction (CATF) is obtained by dividing the number of treatment entrants for cannabis use problems by the number of treatment entrants for any substance use problem, accounting for possible changes in the reporting system. Secondly, comparing the number of treatment entrants for cannabis use problems to the number of people who use cannabis (near) daily yields the treated-user-ratio (TUR), which considers a proxy for treatment need (frequent use). Across 30 countries with available data, the importance of cannabis in European treatment facilities varies greatly (CATF: min = 3%; max = 65%), with lower estimates in Eastern European countries. Across 20 countries with complete data, the CATF has risen from 29.4% in 2013 to 37.1% in 2020. The TUR calculated on 26 countries suggests that about 3 in 100 frequent users have sought treatment for their cannabis use problems. Over time, treatment demand has increased at a slower pace than treatment need in most countries. One in three treatment entrants for substance use problems in Europe are due to cannabis, with large variations between countries. There are indications for a widening treatment gap for cannabis use problems. In countries liberalising cannabis laws, monitoring changes in treatment access and demand is warranted.

Corrigendum: Estimating the prevalence of alcohol-related disorders and treatment utilization in Bremen 2016/2017 through routine data linkage.

[This corrects the article DOI: 10.3389/fpsyt.2023.1002526.].

Road safety implications of the partial legalisation of cannabis in Germany: protocol for a quasi-experimental study.

INTRODUCTION: Germany is reforming its legal approach to cannabis, allowing the possession and cultivation of cannabis for recreational purposes. The objective of this study is to investigate the impact of the policy reform on (1) The prevalence of cannabis use in the general population and (2) Driving under the influence of cannabis (DUIC) among regular users. METHODS AND ANALYSIS: A quasi-experimental research design will be employed, with repeated cross-sectional surveys on self-reported DUIC and cannabis use conducted at three measurement points in Germany (intervention group) and Austria (control group) over a 2-year observation period (2023-2025). Data will be collected from approximately 50 000 individuals aged between 18 years and 64 years. To minimise reporting biases in the measurement of DUIC, we will use direct and indirect assessments via crosswise model and motor vehicle accident data from official statistics. In a difference-in-difference framework, regression analyses and interrupted time series analysis will be carried out for hypothesis testing. ETHICS AND DISSEMINATION: Participants will be informed about voluntary participation, data protection laws and the option to delete data on request. Ethical approval was obtained from the Local Psychological Ethics Committee of the Centre for Psychosocial Medicine in Hamburg, Germany (reference number: 0686). Findings will be disseminated through scientific networks and will be key for a comprehensive evaluation of the cannabis law reform. The findings will facilitate the design and implementation of road safety measures.

Classifying national drinking patterns in Europe between 2000 and 2019: A clustering approach using comparable exposure data.

BACKGROUND AND AIMS: Previously identified national drinking patterns in Europe lack comparability and might be no longer be valid due to changes in economic conditions and policy frameworks. We aimed to identify the most recent alcohol drinking patterns in Europe based on comparable alcohol exposure indicators using a data-driven approach, as well as identifying temporal changes and establishing empirical links between these patterns and indicators of alcohol-related harm. DESIGN: Data from the World Health Organization's monitoring system on alcohol exposure indicators were used. Repeated cross-sectional hierarchical cluster analyses were applied. Differences in alcohol-attributable harm between clusters of countries were analyzed via linear regression. SETTING: European Union countries, plus Iceland, Norway and Ukraine, for 2000, 2010, 2015 and 2019. PARTICIPANTS/CASES: Observations consisted of annual country data, at four different time points for alcohol exposure. Harm indicators were only included for 2019. MEASUREMENTS: Alcohol exposure indicators included alcohol per capita consumption (APC), beverage-specific consumption and prevalence of drinking status indicators (lifetime abstainers, current drinkers, former drinkers and heavy episodic drinking). Alcohol-attributable harm was measured using age-standardized alcohol-attributable Disability-Adjusted Life Years (DALYs) lost and deaths per 100 000 people. FINDINGS: The same six clusters were identified in 2019, 2015 and 2010, mainly characterized by type of alcoholic beverage and prevalence drinking status indicators, with geographical interpretation. Two-thirds of the countries remained in the same cluster over time, with one additional cluster identified in 2000, characterized by low APC. The most recent drinking patterns were shown to be significantly associated with alcohol-attributable deaths and DALY rates. Compared with wine-drinking countries, the mortality rate per 100 000 people was significantly higher in Eastern Europe with high spirits and 'other' beverage consumption [ ß ^ = 90, 95% confidence interval (CI) = 55-126], and in Eastern Europe with high lifetime abstainers and high spirits consumption ( ß ^ = 42, 95% CI = 4-78). CONCLUSIONS: European drinking patterns appear to be clustered by level of beverage-specific consumption, with heavy episodic drinkers, current drinkers and lifetime abstainers being distinguishing factors between clusters. Despite the overall stability of the clusters over time, some countries shifted between drinking patterns from 2000 to 2019. Overall, patterns of drinking in the European Union seem to be stable and partly determined by geographical proximity.

Effectiveness of cannabis use and cannabis use disorder interventions: a European and international data synthesis.

This data synthesis examined the effectiveness of behavioural and pharmacological approaches for cannabis treatment. We integrated findings from high level evidence studies and prioritised data from Europe when available. The synthesis found that only a relatively small number of published behavioural and pharmacological studies on cannabis interventions have been conducted in Europe. Applying both European and non-European data, it was found that Cognitive Behavioural Therapy (CBT) and/or Motivational Enhancement Therapy (MET) improved short-term outcomes in the frequency of cannabis use and dependency severity, although abstinence outcomes were less consistent. These improvements were typically not maintained nine months after treatment. CBT and MET (or combined CBT + MET) treatments that extend beyond four sessions were more effective than fewer sessions over a shorter duration. Combining CBT or MET (or combined CBT + MET) with adjunctive Contingency Management (CM) improved therapeutic outcomes. No pharmacotherapies have been approved for the management of cannabis use, cannabis use disorders or cannabis withdrawal. Despite only weak evidence to support the use of pharmacological agents, some are used 'off-label' to manage withdrawal symptoms outside clinical trials.

Clustering care pathways of people with alcohol dependence using a data linkage of routine data in Bremen, Germany.

BACKGROUND: Although many individuals with alcohol dependence (AD) are recognized in the German healthcare system, only a few utilize addiction-specific treatment services. Those who enter treatment are not well characterized regarding their prospective pathways through the highly fragmented German healthcare system. This paper aims to (1) identify typical care pathways of patients with AD and their adherence to treatment guidelines and (2) explore the characteristics of these patients using routine data from different healthcare sectors. METHODS: We linked routinely collected register data of individuals with a documented alcohol-related diagnosis in the federal state of Bremen, Germany, in 2016/2017 and their addiction-specific health care: two statutory health insurance funds (outpatient pharmacotherapy for relapse prevention and inpatient episodes due to AD with and without qualified withdrawal treatment (QWT)), the German Pension Insurance (rehabilitation treatment) and a group of communal hospitals (outpatient addiction care). Individual care pathways of five different daily states of utilized addiction-specific treatment following an index inpatient admission due to AD were analyzed using state sequence analysis and cluster analysis. The follow-up time was 307 days (10 months). Individuals of the clustered pathways were compared concerning current treatment recommendations (1: QWT followed by postacute treatment; 2: time between QWT and rehabilitation). Patients' characteristics not considered during the cluster analysis (sex, age, nationality, comorbidity, and outpatient addiction care) were then compared using a multinomial logistic regression. RESULTS: The analysis of 518 individual sequences resulted in the identification of four pathway clusters differing in their utilization of acute and postacute treatment. Most did not utilize subsequent addiction-specific treatment after their index inpatient episode (n = 276) or had several inpatient episodes or QWT without postacute treatment (n = 205). Two small clusters contained pathways either starting rehabilitation (n = 26) or pharmacotherapy after the index episode (n = 11). Overall, only 9.3% utilized postacute treatment as recommended. CONCLUSIONS: A concern besides the generally low utilization of addiction-specific treatment is the implementation of postacute treatments for individuals after QWT.

Quantifying alcohol's harm to others: a research and policy proposal.

Just under 2.5 million people die annually due to alcohol use. This global estimate, however, excludes most of the health burden borne by others than the alcohol user. Alcohol's harm to others includes a multitude of conditions, such as trauma from traffic crashes, fetal disorders due to prenatal exposure to alcohol, as well as interpersonal and intimate partner violence. While alcohol's causal role in these conditions is well-established, alcohol's harm to others' contribution to the overall health burden of alcohol remains unknown. This knowledge gap leads to a situation in which alcohol policy and prevention strategies largely focus on the reduction of alcohol's detrimental health harms on the alcohol users, neglecting affected others and population groups most vulnerable to these harms, including women and children. In this article, we seek to elucidate why estimates for alcohol's harm to others are lacking and offer guidance for future research. We also argue that a full assessment of the alcohol health burden that includes the harm caused by others' alcohol use would enhance the visibility and public awareness of such harms, and advancing the evaluation of policy interventions to mitigate them.

Chaque année, un peu moins de 2,5 millions de décès sont liés à la consommation d'alcool. Cette estimation globale ne tient cependant pas compte de l'impact sur la santé de l'entourage des consommateurs d'alcool. Les méfaits de l'alcool sur les autres ont une multitude de conséquences, parmi lesquelles des traumatismes dus aux accidents de la circulation, des anomalies fœtales liées à une exposition prénatale à l'alcool, ainsi que des actes de violence interpersonnelle et entre partenaires. Bien que le rôle causal de l'alcool dans ces problématiques soit bien établi, les répercussions de tels méfaits sur la santé dans son ensemble restent à déterminer. Des lacunes qui aboutissent souvent à une situation dans laquelle les politiques et stratégies de prévention se concentrent principalement sur la diminution des effets néfastes de l'alcool sur la santé des consommateurs eux-mêmes, négligeant les personnes qui les entourent et les catégories de population les plus vulnérables, en particulier les femmes et les enfants. Dans cet article, nous tentons d'expliquer pourquoi il n'existe aucune estimation concernant les méfaits de l'alcool sur les autres et prodiguons des conseils pour de futures recherches. Nous plaidons aussi pour une analyse complète de la charge sanitaire imputable à l'alcool incluant les méfaits de l'alcool sur les autres, afin d'améliorer la visibilité et de mieux sensibiliser l'opinion publique à ces problématiques, mais aussi de faire progresser l'évaluation des interventions politiques entreprises pour y remédier.

Cerca de 2,5 millones de personas mueren cada año por el consumo de alcohol. Sin embargo, esta estimación global excluye la mayor parte de la carga sanitaria que soportan personas que no son consumidores de alcohol. Los daños del alcohol a terceros incluyen multitud de afecciones, como los traumatismos por accidentes de tráfico, los trastornos fetales debidos a la exposición prenatal al alcohol, y la violencia interpersonal y de pareja. Aunque se sabe que el alcohol influye en estas afecciones, se desconoce la contribución de los daños del alcohol a terceros a la carga sanitaria global que supone el alcohol. Esta falta de conocimiento conduce a una situación en la que las estrategias de política y de prevención del alcohol se centran en gran medida en la reducción de los daños perjudiciales del alcohol para la salud de los consumidores de alcohol, dejando de lado a los demás afectados y a los grupos de población más vulnerables a estos daños, incluidas las mujeres y los niños. En este artículo, tratamos de dilucidar por qué faltan estimaciones sobre los daños del alcohol en otras personas y ofrecemos orientaciones para futuras investigaciones. También argumentamos que una evaluación completa de la carga sanitaria del alcohol que incluya los daños causados por el consumo de alcohol de otras personas mejoraría la visibilidad y la concienciación pública de esos daños, y haría avanzar la evaluación de las intervenciones políticas para mitigarlos.

Germany's cannabis act: a catalyst for European drug policy reform?

With the enforcement of the Cannabis Act on 1 April 2024, Germany has adopted one of the most liberal legal approaches to cannabis on the continent. The German model prioritises a non-profit approach and precludes legal market mechanisms. We believe these are the main drivers for increasing cannabis use and related health problems, based on observations following cannabis legalisation in Canada and many states in the U.S. Although legalising cannabis possession and cultivation may not immediately eliminate the illegal market, it is expected to serve public health goals. Despite the overall positive evaluation of the Cannabis Act in Germany, there are three potential areas of concern: the potential for misuse of the medical system, the normalization of cannabis use, and the influence of the cannabis industry. The German model may herald the beginning of a new generation of European cannabis policies, but concerted efforts will be required to ensure that these policy reforms serve rather than undermine public health goals.

National and regional prevalence of interpersonal violence from others' alcohol use: a systematic review and modelling study.

Background: While alcohol use is an established risk factor for interpersonal violence, the extent to which people are affected by interpersonal violence from others' drinking has not yet been quantified for different world regions. This modelling study aims to provide the first estimates of the national and regional prevalence of interpersonal violence from others' drinking. Methods: An international systematic literature search (02/28/2023, Prospero: CRD42022337364) was conducted to identify general adult population studies assessing the prevalence of interpersonal violence from others' drinking with no restrictions to publication date or language. Reports that did not provide data on interpersonal violence from others' drinking (primary outcome), were no original research studies, or captured a selected group of people only, were excluded. Observed prevalence data were extracted and used to build fractional response regression models to predict past-year prevalence of emotional and physical violence from others' drinking in 2019. Random-effects meta-regression models were used to aggregate the observed prevalence of sexual and intimate partner violence. Study risk of bias (ROB) was assessed using a modified version of the Newcastle-Ottawa Scale. Findings: Out of 13,835 identified reports, 50 were included covering just under 830,000 individuals (women: 347,112; men: 322,331; men/women combined: 160,057) from 61 countries. With an average prevalence of 16·8% (95% CI: 15·2-18·3%) and 28·3% (95% CI: 23·9-32·4%) in men and women combined in the GBD super regions High Income and Central Europe, Eastern Europe, & Central Asia, respectively, emotional violence was the most common form of interpersonal violence from others' drinking. Physical violence averaged around 3% (women) and 5% (men) in both regions. The pooled prevalence of sexual violence from others' drinking in men and women was 1·3% (95% CI: 0·5-3·3%, 95% PI: 0·1-16·9%) and 3·4% (95% CI: 1·4-8·3%, 95% PI: 0·2-35·3%), respectively, and ranged between 0·4% (95% CI: 0·1-1·6%, 95% PI: 0·0-7·3%) and 2·7% (95% CI: 1·1-6·3%, 95% PI: 0·2-30·0%) for different forms of intimate partner violence. ROB was moderate or critical for most reports; accounting for critical ROB did not substantially alter our results. Interpretation: The share of the population experiencing harms from others' drinking is significant and should be an integral part of public health strategies. Funding: Research reported in this publication was supported by the Canadian Institutes of Health Research (CIHR; grant: CIHR FRN 477887).

Cannabis use and cannabis use disorders and their treatment in the Europe.

This paper introduces the special issue on cannabis use in Europe. It describes data on the prevalence of cannabis use in Europe and the more limited data on the prevalence of cannabis use disorders, one of the most common forms of drug problem treated in many countries in Europe. It summarises what research has indicated about the adverse effects of acute and chronic cannabis use and discusses potential health system responses that may reduce some of these harms. These include public education about the risks of cannabis use; screening and brief interventions in primary medical settings; and specialist treatment for cannabis use disorders. It briefly indicates the special issues that may need to be addressed in dealing with the high rates of comorbidity between cannabis use disorders, other types of drug use disorders, and common mental disorders.

Cannabis use, health problems, and criminal offences in Germany: national and state-level trends between 2009 and 2021.

The German federal government plans to decriminalise cannabis. The impact of this policy on use prevalence, cannabis-related health and legal problems cannot be fully anticipated and should be viewed in context with current trends. We used routine data on (a) cannabis use (population-based surveys), (b) cannabis-related diagnoses (ICD-10 code F12) in outpatient medical settings and (c) minor law offences (registered violations against the narcotics law for possessing small amounts) to analyse age and sex-specific trends by federal state between 2009 and 2021. To enable comparisons across time and federal state besides crude prevalence rates, age-standardised rates were calculated. Between 2009 and 2021, the age-standardised prevalence of cannabis use (5.7-10.6%), rate of diagnoses (1.1-3.7 per 1,000), and legal offences (1.8-3.1 per 1,000) increased, with the largest increase noted for cannabis-related diagnoses. Relatively, increases were most pronounced for older users (40-to-59-year-olds: use and offences; 35-to-44-year-olds: cannabis-related diagnoses) and rather stagnant for minors. Cannabis use and health problems appear to be more pronounced in Northern and city states, while no clear geographic trend was observed for law offences. Cannabis-related outpatient treatment demand has risen more steeply than use prevalence suggesting an increasing challenge for the health care system. Despite rising rates for documented offences, the long-term implications of law violations on social and occupational life are poorly understood but may be considered for evaluations of the proposed law changes.

The Impact of Raising Alcohol Taxes on Government Tax Revenue: Insights from Five European Countries.

BACKGROUND AND OBJECTIVE: Reducing the affordability of alcoholic beverages by increasing alcohol excise taxation can lead to a reduction in alcohol consumption but the impact on government alcohol excise tax revenue is poorly understood. This study aimed to (a) describe cross-country tax revenue variations and (b) investigate how changes in taxation were related to changes in government tax revenue, using data from Estonia, Germany, Latvia, Lithuania and Poland. METHODS: For the population aged 15 years or older, we calculated the annual per capita alcohol excise tax revenue, total tax revenue, gross domestic product and alcohol consumption. In addition to descriptive analyses, joinpoint regressions were performed to identify whether changes in alcohol excise taxation were linked to changes in alcohol excise revenue since 1999. RESULTS: In 2022, the per capita alcohol excise tax revenue was lowest in Germany (€44.2) and highest in Estonia (€218.4). In all countries, the alcohol excise tax revenue was mostly determined by spirit sales (57-72% of total alcohol tax revenue). During 2010-20, inflation-adjusted per capita alcohol excise tax revenues have declined in Germany (- 22.9%), Poland (- 19.1%) and Estonia (- 4.2%) and increased in Latvia (+ 56.8%) and Lithuania (+ 49.3%). In periods of policy non-action, alcohol consumption and tax revenue showed similar trends, but tax level increases were accompanied by increased revenue and stagnant or decreased consumption. CONCLUSIONS: Increasing alcohol taxation was not linked to decreased but increased government revenue. Policymakers can increase revenue and reduce alcohol consumption and harm by increasing alcohol taxes.

Restricting alcohol marketing to reduce alcohol consumption: A systematic review of the empirical evidence for one of the 'best buys'.

BACKGROUND AND AIMS: Even though a ban of alcohol marketing has been declared a 'best buy' of alcohol control policy, comprehensive systematic reviews on its effectiveness to reduce consumption are lacking. The aim of this paper was to systematically review the evidence for effects of total and partial bans of alcohol marketing on alcohol consumption. METHODS: This descriptive systematic review sought to include all empirical studies that explored how changes in the regulation of alcohol marketing impact on alcohol consumption. The search was conducted between October and December 2022 considering various scientific databases (Web of Science, PsycINFO, MEDLINE, Embase) as well as Google and Google Scholar. The titles and abstracts of a total of 2572 records were screened. Of the 26 studies included in the full text screening, 11 studies were finally included in this review. Changes in consumption in relation to marketing bans were determined based on significance testing in primary studies. Four risk of bias domains (confounding, selection bias, information bias and reporting bias) were assessed. RESULTS: Seven studies examined changes in marketing restrictions in one location (New Zealand, Thailand, Canadian provinces, Spain, Norway). In the remaining studies, between 17 and 45 locations were studied (mostly high-income countries from Europe and North America). Of the 11 studies identified, six studies reported null findings. Studies reporting lower alcohol consumption following marketing restrictions were of moderate, serious and critical risk of bias. Two studies with low and moderate risk of bias found increasing alcohol consumption post marketing bans. Overall, there was insufficient evidence to conclude that alcohol marketing bans reduce alcohol consumption. CONCLUSIONS: The available empirical evidence does not support the claim of alcohol marketing bans constituting a best buy for reducing alcohol consumption.

Cannabis Use in Germany.

BACKGROUND: The federal government of Germany is planning to liberalize the recreational cannabis market for adults. We aimed to collect key baseline data on frequency of use, routes of administration, and co-use of cannabis and inhaled nicotine or tobacco products in the population. METHODS: Based on data from a national survey of 9644 people aged >14 years, we analyzed self-reported use of cannabis in the past 12 months and preferred route of administration (single choice: smoked with tobacco; smoked without tobacco; inhaled without tobacco; consumed with food; consumed in another form). RESULTS: The prevalence of past-year cannabis use was 4.6% (95% CI [4,2; 5,1%]), with higher rates among 14-24- (11.4%) and 25-39-year-olds (8.2%) as well as among co-users of inhaled nicotine or tobacco products, particularly waterpipe users (27.0%). Smoking cannabis with or without tobacco was the preferred route of administration, reported by 92.4% (95% CI [89,6; 94,6%]). It was most frequently reported by 14-24-year-olds and by co-users of inhaled nicotine or tobacco products. CONCLUSION: Smoking remains the predominant form of using cannabis-especially among younger users, who are at greatest risk of cannabis-related consequences. The true prevalence of cannabis use may have been underestimated in our study, however, as not all participants answered the questions on cannabis. Nevertheless, preventive and harm reduction efforts are needed to reduce the harm from using cannabis. Continuous monitoring is required to evaluate the effects of the forthcoming law changes in Germany.