"Nicotine initiation products in Germany: Findings from a representative survey of individuals aged 14 years and older who had ever used nicotine-containing products".

INTRODUCTION: Smoking prevalence in Germany has remained high in recent years, with around 30 % of the population smoking. Related nicotine products, such as e-cigarettes, are increasingly popular, especially among youth. Unlike previous generations, for whom nicotine use typically began with traditional cigarettes, initiation pathways may now increasingly involve these related nicotine products. METHODS: Data from 1,164 participants aged 14 years and older were collected between August and September 2022 through the DEBRA study (German Study on Tobacco Use), using computer-assisted household interviews. Descriptive statistics analysed the frequency of nicotine initiation products, grouped into traditional tobacco products (tobacco cigarettes, pipes/cigars/cigarillos) and related tobacco and nicotine products (heated tobacco products, e-cigarettes with nicotine, waterpipes, chewing tobacco/snuff, nicotine pouches/snus and cannabis mixed with tobacco). Associations between initiation product category and sociodemographic factors (age, sex, migration background, education, and income) were analysed using univariate binary logistic regression. RESULTS: Tobacco cigarettes were the most common nicotine initiation product, reported by 84.3 % of individuals with ever use of nicotine containing products. Initiation with related products was more common among younger and higher educated individuals: ages 14-17 (OR = 17.42, 95 %CI = 4.6-66.02), ages 18-25 (OR = 10.95, 95 %CI = 5.24-22.89) compared with those aged 65 and older, and among individuals with high vs. low educational attainment (OR = 1.93, 95 %CI = 1.24-3.02). DISCUSSION: Traditional cigarettes remain the most common nicotine initiation product in Germany. However, younger and higher educated individuals are more likely to initiate with related products. These findings highlight changing initiation patterns and underscore the importance of considering alternative nicotine products when addressing pathways into nicotine dependence and their long-term public health implications.