Daniel Kotz’s research while affiliated with Universitätsklinikum Düsseldorf and other places

Background Chronic ischemic heart disease (IHD) is one of the leading causes of morbidity and mortality. Physical activity (PA) is an effective secondary preventive strategy in IHD management. The German treatment guideline recommends that general practitioners (GPs) deliver PA advice to patients. This recommendation seems inadequately implemented, often due to GP’s insufficient specific training. International guidelines recommend training GPs in how to deliver such advice effectively and efficiently. Evidence is lacking on whether such training can enhance the frequency and quality of PA advice in routine care. The OptiCor project aims to develop and evaluate a GP training in the delivery of very brief PA advice to optimise the treatment of patients with IHD in general practice. Methods OptiCor comprises three study phases according to the Medical Research Council recommendations for developing and evaluating complex interventions. Phase 1 (needs analysis): A nationwide representative household survey will be conducted to collect data on the receipt of GP-delivered PA advice in people with IHD. Qualitative interviews and group discussions with GPs and people with IHD will help to explore, e.g., attitudes, experiences with, and barriers and facilitators of PA advice implementation or reception, respectively. Findings will inform the training development. Phase 2 (pilot): A pragmatic cluster randomised controlled trial (cRCT) on the effectiveness of the developed training on proportions of GP-delivered PA advice during routine care of IHD patients will be piloted. Phase 3 (evaluation): A full pragmatic cRCT will be conducted with patient-reported proportions of GP-delivered PA advice as primary endpoint. Collection of health economic and process-related data will facilitate a potential future broad implementation and health economic evaluation of the training. Discussion If the developed training successfully improves proportions and quality of GP delivered PA advice to patients with IHD, it could serve as a low-threshold and sustainable strategy for implementing PA recommendations in the secondary prevention of IHD in routine GP practice. Trial registration Work package (WP) 1, WP5, and WP6 have been prospectively registered at German Clinical Trials Register (WP1: DRKS00031304, 19/06/2023; WP5: DRKS00034641, 10/07/2024; WP6: DRKS00034642; 10/07/2024).

Aims To provide data on prevalence and trends in the use of different types of e‐cigarettes (disposable, pod, tank) in Germany (a country with high smoking prevalence of approximately 30%) from 2016 to 2023, and to analyse the characteristics and smoking behaviours of users of these types. Design A series of nationally representative cross‐sectional face‐to‐face household surveys. Setting General population of Germany, 2016–2023. Participants A total of 92 327 people (aged ≥14 years) of which 1398 reported current use of e‐cigarettes. Measurements Type of e‐cigarette usually used (single choice: disposable, pod, or tank), person characteristics, and smoking/vaping behaviour. Findings E‐cigarette use in the population of Germany has increased from 1.6% (95% confidence interval [CI] = 1.1,2.2) in 2016 to 2.2% (95% CI = 1.6,3.0) at the end of 2023. Disposable e‐cigarette use has increased in this period from 0.1% (95% CI = 0.0,0.3) to 0.8% (95% CI = 0.4,1.8). Pod type use exhibited the most stable trend, with a steady rise to 0.6% (95% CI = 0.4,0.9) in 2023. Tank e‐cigarette use peaked at 1.6% (95% CI = 1.3,1.9) in November 2017, declined to 0.7% (95% CI = 0.6,0.9) in December 2020, and has since remained constant at 0.8% (95% CI = 0.6,1.0). Disposable e‐cigarette users were on average 3.5 and 4.1 years younger than tank and pod users, respectively. They were more likely than tank users to be female, non‐daily users, and dual users of tobacco. In the subgroup of dual users, there were no significant differences with regard to urges to smoke, cigarettes smoked per day, motivation to stop, and attempts to stop smoking between users of disposables and other types. Conclusions The use of e‐cigarettes has increased in Germany from 2016 to 2023, especially that of disposable e‐cigarettes, which are now the most commonly used type with a prevalence rate of 0.8%. However, the use of e‐cigarettes is still much lower compared with tobacco smoking.

Purpose The German treatment guideline “chronic ischemic/coronary heart disease (IHD)” recommends that general practitioners (GPs) deliver advice on physical activity (PA) to IHD patients. This recommendation is inadequately implemented, often due to GP’s insufficient specific training. International guidelines recommend training GPs in how to deliver PA advice effectively and efficiently. Evidence is lacking on how such training should be designed to match the recipients’ needs, and whether it improves the frequency and quality of advice. With OptiCor we aim to systematically develop and evaluate such a training for GPs to optimise the routine care of IHD patients. Project OptiCor has started in 2022. It comprises three phases over five years. The methodology matches the Medical Research Council framework recommendations for complex interventions. GPs and patients are substantially involved throughout the entire project. OptiCor (funded by the German Ministry of Education and Research) will be presented internationally for the first time. Phase 1 (needs analysis/development)–completed: A nationwide, face-to-face household survey was used to collect data on the receipt of GP-delivered PA advice in people with IHD. Focus group discussions and problem-centred interviews were conducted with GPs and patients with IHD to explore attitudes and motivation towards, experiences with, and barriers and facilitators of PA advice implementation or reception, respectively. The findings are now being used to inform the theory-based training development. Phase 2 (pilot): A pragmatic cluster randomised controlled trial (cRCT) on the effectiveness of the GP training on delivered PA advice during routine care of IHD patients will be pilot tested in summer 2024. Phase 3 (evaluation): A full pragmatic cRCT will be conducted from 2025 onwards (primary endpoint: patient-reported proportions of GP-delivered PA advice). Health economic and process-related analyses will facilitate a potential future broad dissemination and health economic evaluation of the training. Conclusions If our training successfully enhances the proportions and quality of delivered PA advice to IHD patients, it represents a low-threshold strategy for a broad implementation in general practice. The training could extend existing projects on PA referral/prescription schemes, and it could be transferred to the management of other diseases or to other healthcare settings.

Purpose The current German treatment guideline “chronic ischemic heart disease (IHD)” recommends that general practitioners (GPs) deliver advice on physical activity (PA) to patients with IHD. Such advice is particularly effective in motivating individuals to increase their PA when it consists of three elements: (1) asking for/assessing the PA level, (2) advising on PA, and (3) assisting with PA (e.g., providing concrete support/recommendations). However, in Germany, current and representative data on the receipt of these elements of GP advice in individuals with IHD is lacking. This study aims at collecting such data on a population level. Methods Nationwide, computer-assisted, face-to-face cross-sectional survey of ≃1000 individuals (35+ years) with self-reported IHD on the receipt of the three elements of GP advice on PA (ask/assess, advise, assist) since their last remembered IHD-event/intervention (e.g., myocardial infarction, stent insertion). The survey started in June 2023 and will continue until May 2024. Six of eight survey waves have been completed. When the complete data set is available, associations with person characteristics (e.g., sex, income, region of living, body mass index, PA level) will be analysed using adjusted regression models. Results on the associations will be presented at the conference. Results Of the current sample of 682 individuals with IHD, 35.3% (95% confidence interval (CI) = 32-39) received all three elements of GP advice (ask/assess, advise, assist), 44.4% (95%CI = 41-48) received one or two elements (e.g., ask/assess only), and 10.0% (95%CI = 8-12) received any advice (2.9% received the advice to refrain from PA, 7.3% did not remember/refused to answer). Men (38.0%; 95%CI = 34-43) versus women (30.5%; 95%CI = 25-36), individuals from urban (40.7%; 95%CI = 36-46) versus rural regions (26.2%; 95%CI = 21-32), and those with a PA level of 1-149 minutes/week (43.1%; 95%CI = 36-51) and of 150+ minutes/week (39.0%; 95%CI = 31-47) versus non-active individuals (20.7%; 95%CI = 15-28) reported the receipt of all elements of PA advice more often. Conclusions In Germany, about one third of individuals with IHD received all relevant elements of GP advice on PA since their last IHD-event/intervention. In order to increase the delivery and enhance the effectiveness of GP advice, target group-specific measures need to be implemented. Funding German Ministry of Education and Research (01GY2103).

Background Physical inactivity and tobacco smoking remain leading causes of morbidity and mortality worldwide. In Germany, smoking prevalence is high at around 30% and only 45% achieve the World Health Organization recommendation for physical activity (PA). Understanding how smoking and physical inactivity co-occur can inform interventions targeting these behaviours. Methods We analysed data from 4,073 adults (≥18 years) participating in a national household survey between April and July 2022. We tested the association between PA level (not=reference/low/medium/very active) and smoking status (never=reference/ex/current smoker). Among current smokers, we tested associations between PA level and cigarettes smoked per day; time spent with, and strength of, urges to smoke; and motivation to stop smoking. Results Overall, 29.9% (95%CI=28.5;31.4) reported no leisure time PA; among current smokers it was 39.8% (95% CI=37.3;42.4). Higher PA levels were associated with lower odds of being a current vs. never smoker (OR=0.74, 95%CI=0.69;0.79). Among current smokers, higher PA levels were associated with smoking fewer cigarettes per day (β=-0.98,95%CI=-1.39;-0.56), weaker urges to smoke (OR=0.81,95%CI=0.74;0.89), and higher motivation to stop smoking (OR=1.13,95%CI=1.02;1.24). Time spent with urges to smoke showed a small overlap in the upper CI (OR=0.93,95%CI=0.85;1.02). Conclusion People who are more physically active are less likely to smoke. Current smokers with higher PA levels smoke less, are less dependent, and more motivated to quit. Further research is required to determine whether these associations are causal and, if so, whether interventions to increase PA could help people to quit smoking.

Introduction On 1st of April 2024 a law on cannabis legislation entered into force in Germany. Henceforth, a rise in cannabis consumption rates and consequently cannabis related health impacts is expected. Preventive measures are only possible if harmful use is recognised and addressed at an early stage. We set up to estimate the proportion of cannabis users in Germany that discussed their cannabis consumption with their general practitioner (GP), either on the initiative of the GP or the patient, and how these varied according to person characteristics. Methods We used data from the German Study on Tobacco Use (DEBRA). This is a repeated ongoing representative cross-sectional household survey on use of tobacco and alternative nicotine delivery systems in Germany in people aged 14 years and older. During bimonthly study waves we asked all respondents who stated that they had consumed cannabis before whether they had ever spoken with their GP about their cannabis use or received advice about it. We estimated the proportion including 95% confidence intervals and assessed possible associations with person characteristics by using univariate logistic regression models. Results Of 2,057 ever users of cannabis, 7.0% [95%CI = 5.9; 8.2%] (n = 139) answered “Yes, I have ever spoken to my general practitioner about my cannabis use or sought advice in this regard”. This response was associated with older age (65+), low educational attainment, low income, and frequent cannabis use. Conversation with a GP was also more common in past-year cannabis users (16.2% [95%CI = 13.5; 19.6%], n = 591). Conclusions Around one in fifteen cannabis users has ever spoken with his or her GP, or received advice, about his or her cannabis consumption. In past-year and frequent users, the proportions are highest, between 16 to 26%. The awareness of this topic among GPs needs to be increased. Furthermore, a future re-evaluation on what impact the legislation of cannabis will have on the frequency of consultation about cannabis consumption in primary care is necessary.

Zusammenfassung Sowohl die Tabakentwöhnung als auch ein Low-dose-CT-Screening bei Risikopersonen senken die lungenkrebsspezifische Mortalität und die Gesamtmortalität. Im Rahmen eines nationalen Screeningprogramms zur Früherkennung von Lungenkrebs muss die Tabakentwöhnung obligater Bestandteil der Beratung der Teilnehmenden sein. Hierdurch wird auch die Kosten-Nutzen-Effektivität des Screeningprogramms gesteigert. Im Rahmen des Erstgesprächs müssen Teilnehmenden des Screeningprogramms in Form einer Minimalintervention evidenzbasierte Maßnahmen zur Tabakentwöhnung angeboten werden. Bei nicht gewünschter Tabakentwöhnung müssen Teilnehmende des Screeningprogramms aktiv widersprechen (Opt-out-Regelung). Die Kosten für die Tabakentwöhnung inklusive der Kosten für eine entzugshemmende Medikation sind durch die Gesetzliche Krankenversicherung vollständig zu übernehmen.

Background Tobacco cigarettes, e-cigarettes and heated tobacco products can pose different health risks (harm continuum). As current tobacco smokers could benefit from switching to less harmful products, we aimed to assess current smokers’ perceived comparative health risks of these three products and to explore associations between risk perceptions and specific user characteristics. Methods We analysed data from 11 waves (2019–2021; N = 5657 current tobacco smokers) of a representative, cross-sectional household survey conducted in Germany. Associations were assessed with multivariable logistic regression models. Results 55.2% of smokers (95%CI = 53.8–56.5%) ranked cigarettes as the most harmful product. 36.1% of smokers (95%CI = 34.8–37.3%) perceived e-cigarettes and 33.8% (95%CI = 32.5–35.0%) heated tobacco products as more harmful than cigarettes. Misperceptions that e-cigarettes or heated tobacco products are more harmful to health than cigarettes increased over the 3-year study period and were more common among those with lower educational attainment. Conclusions Only half of current tobacco smokers in Germany perceive the comparative health risks of cigarettes adequately and such misperceptions have increased recently. As current smokers could benefit most from switching to less harmful products, educational campaigns are needed to inform this group about the health risks of tobacco smoking and the comparative health risks of the various nicotine and tobacco products along the harm continuum.