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Background: Maternal smoking during pregnancy represents a significant developmental risk for the unborn child. This study investigated social differences in maternal smoking behavior during pregnancy in mothers living in Germany. The study focused on maternal age at delivery, social status and migration background. Method: The evaluation of data was based on two surveys carried out as part of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) carried out in 2003-2006 and in 2009-2012. The study compared the information given by parents of children aged between 0 and 6 years who were born either in the period from 1996 to  2002 (KiGGS baseline study, n = 4818) or in the period from 2003 to 2012 (KiGGS Wave 1, n = 4434). Determination of social status was based on parental educational levels, occupational position and income. Children classified as having a two-sided migration background either had parents, both of whom had immigrated to Germany, or were born abroad and had one parent who had immigrated to Germany; children classified as having a one-sided migration background had been born in Germany but had one parent who had immigrated to Germany. Results: The percentage of children whose mothers had smoked during pregnancy was 19.9 % for the older birth cohort and 12.1 % for the younger birth cohort. In both birth cohorts, the probability of being exposed to tobacco smoke was twice as high for children whose mothers were aged < 25 years at delivery compared to the children of older mothers. Children from socially deprived families were most affected by smoking behavior, and the relative social differences were found to have even increased over time (KiGGS baseline study: OR = 6.34; 95 % CI = 4.53-8.86; KiGGS Wave 1: OR = 13.88; 95 % CI = 6.85-28.13). A two-sided migration background was associated with a lower risk of exposure to smoking. Conclusions: The KiGGS results are in accordance with the results of other national and international studies which have shown that the percentage of mothers who smoke during pregnancy is declining. Because of a change in the method how data are collected for the KiGGS survey (written questionnaire vs. telephone interview) the trend results must be interpreted with caution. Measures aimed at preventing smoking and weaning women off smoking should focus particularly on younger and socially deprived mothers.

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Introduction: Energy consumption, i. e., the metabolic equivalent of task (MET), provides a precise assessment of physical activity (PA). Studies on social inequalities of PA have hardly used this possibility, however. Methods: The analyses are based on the 'Motorik-Modul (MoMo) of the KiGGS study (German Health Interview and Examination Survey for Children and Adolescents) conducted between 2003 and 2006 (n=1 757; age group 11-17 years). PA has been assessed in 3 settings (sport club in school, other sport club, leisure time). 3 dependent variables were distinguished by combining the following criteria: at least 21 MET-hours per week, intensity between 3 and 6 METs, at least 7 hours a week. The main independent variables are: type of school and socioeconomic status (SES) of the parents. 'Two part models' have been used to assess social difference in PA among those who are physically active. Results: PA is much more common in the higher SES groups. Looking at the MET-hours, though, there are just little differences among those who are physically active (regressions coefficient for low vs. high SES: 1.15; 95% conf. interv. 0.99-1.33). Conclusion: Social differences can be seen mainly for the proportion of adolescents being physically active, not for the extent of PA among those who are physically active. Therefore, the central request should be to increase the proportion of adolescents performing any PA in the low SES group.

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In health research, socio-economic status (SES) is traditionally assessed using objective indicators (education, occupation, income). For a couple of years, there has been a growing body of studies that additionally assess the subjective social status (SSS) of respondents, mostly using the MacArthur Scale. The aim of this study was to examine the construct validity of a German-language version of this instrument and to investigate whether SSS is associated with health over and above objective SES. Analyses were based on data from a population-based pilot study carried out within the 'German Health Update' (GEDA) study conducted by the Robert Koch Institute (n = 1,571; age: 18-79 years). SSS was measured with the MacArthur scale asking respondents to place themselves on a 10-rung "social ladder". The strongest correlations to SSS were found with measures of similar constructs such as a multidimensional index of objective SES, income level, occupational position and educational attainment (r = 0.32-0.60; p < 0.001). Weaker correlations were found between SSS and measures of dissimilar constructs such as social support, mental well-being, depressiveness, and body-mass-index (r = - 0.29-0.30; p < 0.001). Factor analysis did not show considerable loadings of SSS on factors of mental well-being and depressiveness. After adjusting for age, education, occupation, and income, lower SSS remained significantly associated with higher odds of adverse health (p < 0.05). The findings of this study provide support for the convergent and discriminant validity of the MacArthur Scale and indicate that self-perceptions of social disadvantage may have health implications beyond the impact of objective SES.

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BACKGROUND: At the beginning of the 21st century, waterpipe (shisha) smoking has become a new and global youth trend in tobacco consumption. Despite the fact that this type of tobacco use can also lead to serious health problems, there are only a few studies on this topic in Germany. OBJECTIVES: The aim of this study was to determine the prevalence of waterpipe smoking among 12- to 17-year-old adolescents. Age- and sex-related differences were analyzed and, for the first time in Germany, the association between parental socioeconomic status and waterpipe use was examined. MATERIALS AND METHODS: Data were obtained from the first follow-up of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS Wave 1), which was conducted from 2009 to 2012. Waterpipe smoking was assessed among adolescents aged 12 to 17 years using three items (n = 4,543). We calculated prevalence rates and age-adjusted odds ratios (OR) with 95 % confidence intervals (95 % CI). RESULTS: Lifetime prevalence of waterpipe use was 28.9 % (95 % CI: 26.9-31.0). Approximately one fifth (20.6 %; 95 % CI: 18.8-22.6) of the adolescents reported waterpipe use in the past 12 months, one tenth (10.0 %; 95 % CI: 8.6-11.6) reported current use (at least once during the past 30 days). In both sexes, prevalence increased with age. Waterpipe smoking rates were significantly higher among boys than girls, while no significant differences were found regarding parental socioeconomic status. CONCLUSIONS: A considerable number of adolescents in Germany are at least occasional waterpipe (shisha) smokers. Because of waterpipe related health and addiction risks that are often underestimated by adolescents, specific health education and prevention measures are necessary.

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BACKGROUND: Negative patterns of health behaviour regarding health are developed and solidified internalised in adolescence. In later years, they can lead to diseases which contribute to a high burden of disease, reduced quality of life and premature mortality in later years. The purpose of this analysis is the identification of clusters with different health behavioural types and the characterisation of cluster membership on the basis of different socio-economic and socio-demographic factors. METHODS: Based on the dataset of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), 6,813 adolescents aged between 11 and 17 years were included in the identification of the clusters by a 2-step cluster analysis. Subsequent to the discriminant analysis for testing the stability and validity of the cluster solutions, the associations between cluster membership and possible determinants were evaluated by binary logistic analysis. RESULTS: After that adolescents aged 11-13 years could be merged to 5 clusters, whilst adolescents aged 14-17 years could be merged to 3 clusters. In both age groups, clusters manifesting tendencies conducive to and clusters manifesting tendencies not conducive to health promotion could be identified. In these clusters, the strongest association between cluster membership and the determining factors (e. g., smoking status of friends, health status) could be found. Primarily responsible for cluster generation were physical activity as well as tobacco and alcohol consumption. CONCLUSION: The results of this analysis--especially the identification of clusters based on adolescents with behavioural patterns unconducive to long-term health--represent a contribution to creating interventions specific to target groups with regard to preventative education and health promotion.

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In this paper, tobacco and alcohol consumption among adolescents in Germany was analyzed. In addition to the current situation, we report temporal developments and trends. Data were obtained from the first follow-up of the KiGGS study (KiGGS Wave 1) conducted from 2009 to 2012. All girls and boys aged 11-17 years (n = 5,258) were included. The results show that currently 12.0% of 11- to 17-year-old adolescents in Germany smoke, 5.4% of them on a daily basis. At-risk drinking (AUDIT-C total score) was prevalent among 15.8% of adolescents, heavy episodic drinking (six or more alcoholic standard drinks on a single occasion at least once a month) among 11.5%. No significant gender differences were found for most indicators. However, among adolescents aged 14-17 years, boys revealed a greater inclination toward heavy episodic drinking than girls did (23.1 vs. 16.5 %, p < 0.01). Regarding smoking, distinct socioeconomic differences were observed. For example, adolescents from families with a low socioeconomic status (SES) smoke significantly more often on a regular or daily basis compared with their peers from high-SES families (OR = 1.95, 95% CI = 1.16-3.27 and OR = 3.71, 95% CI = 2.05-6.69, respectively). The relationship between SES and alcohol consumption is rather weak. Significant differences emerged only regarding lifetime prevalence of alcohol consumption, and indicate lower consumption rates among low-SES compared with high-SES adolescents (OR = 0.47, 95% CI = 0.33-0.68). Consideration of the KiGGS baseline study data (2003-2006) shows that smoking prevalence has dropped almost by half from 20.4 to 12.0%. The percentage of adolescents who have ever drunk alcohol has decreased from 62.8 to 54.4%. These results are consistent with the findings of other studies on adolescent tobacco and alcohol consumption and should be considered in the context of preventive efforts that have been strengthened in recent years, especially regarding tobacco use.

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Physical activity during childhood and adolescence has numerous health benefits, while sedentary behavior, especially electronic media use, is associated with the development of overweight. Therefore, the promotion of physical activity during childhood and adolescence is an integral part of national public health efforts. The aim of this article is to describe the physical activity behavior of German children and adolescents based on the nationwide data of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS wave 1). Furthermore, the association between physical activity and sports participation and use of screen-based media in youth aged 11 to 17 years was analyzed. The analyses included data from 10,426 children and adolescents aged 3-17 years collected by telephone interviews. Children older than 11 years answered the questions by themselves, whereas a parent was interviewed for younger children. The descriptive analyses were performed under consideration of social and demographic factors. According to the results of KiGGS wave 1 a total of 77.5% (95% Cl 76.0-78.9 %) of the children and adolescents participated in sports activities, and 59.7% (58.1-61.3 %) were members of a sports club. The recommendation of the World Health Organization (WHO) to be physically active at least 60 min per day was achieved by 27.5% (26.0-28.9 %). Children and adolescents with a low socioeconomic status (SES) participated less in sports activities than children of higher SES groups. Excessive use of screen-based media was more likely to be associated with lack of sports participation than with a lack of physical activity. In the future, preventive measures should promote the daily physical activity of children and adolescents and additionally encourage children and adolescents with low SES to participate in sports activities.

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On the basis of data from KiGGS Wave 1, the following manuscript investigates potential differences in the health status of children and adolescents aged 3-17 years according to the family form they live in: nuclear, single-parent, or stepfamily (n = 10,298). Additionally, we investigate whether differences persist after controlling for age, gender, living area, parental social status, and getting along in the family. Parent-rated health, chronic diseases, emotional or behavior problems, health-related quality of life, and daily consumption of fruits and vegetables were analyzed (prevalence, odds ratios). While the parent-rated health was independent of the family form, the prevalence of the other outcomes differed significantly according to the family form. Emotional or behavior problems were measured more often among children and adolescents growing up in single-parent families (OR 1.62; 95% CI 1.17-2.26) or stepfamily households (OR 2.36; 95% CI 1.63-3.41) than among those growing up in nuclear families, after adjusting for age, gender, living area, social status, and getting along in the family. Additionally, children and adolescents from single-parent families had chronic diseases (OR 1.53; 95% CI 1.20-1.96) more often than their counterparts who lived together with both parents. Compared with those growing up in nuclear families, children and adolescents from stepfamilies showed a greater risk of lower health-related quality of life (OR 2.91; 95% CI 1.76-4.80) and of lower daily consumption of fruits and vegetables (OR 1.30; 95% CI 1.01-1.67). The results indicate the importance of the family context for the health of children and adolescents.

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BACKGROUND: Studies show that adolescents attending upper secondary schools are less likely to smoke than their peers attending lower secondary school types. This article examines how educational differences in smoking behaviour continue in young adulthood. Besides frequency and intensity of tobacco use the main focus is on smoking cessation. METHODS: The analyses were based on information of the 18- to 29-year-old men and women who participated in the nationwide representative telephone survey "German Health Update" (GEDA) 2009 and 2010 carried out by the Robert Koch Institute (n=7,620). Smoking behaviour was measured by several questions on smoking frequency and intensity. Educational status was assessed by the highest school-leaving certificate and classified as low (no school-leaving certificate/Hauptschule certificate), middle (General Certificate of Secondary Education/Realschule certificate), and high (general qualification for university entrance (Abitur)/advanced technical college entrance qualification). In addition to prevalence estimates, age-adjusted odds ratios (OR) and corresponding 95% confidence intervals (95% CI) were calculated using logistic regression. RESULTS: According to the GEDA study, the prevalence of smoking was 42.6% among men and 36.7% among women aged 18-29 years. The prevalence of current smoking increased with decreasing educational level. The odds of current smoking was 3.72-times higher in lower as compared to higher educated men (95% CI 2.90-4.77) and 3.00-times higher in lower as compared to higher educated women (95% CI 2.30-3.92). Moreover, high intensity of tobacco use was also associated with lower education in men and women. The odds of successful quitting was significantly reduced in the lowest compared to the highest educational group (men: OR=0.45; 95% CI 0.31-0.66; women: OR=0.65; 95% CI 0.44-0.94). CONCLUSION: Our findings suggest that young adults with low education are more likely to start smoking and less likely to quit than their higher educated peers. Therefore, tobacco prevention and cessation initiatives should more focus on lower educated young adults.

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In the present study the relation between overweight/obesity and health-related quality of life (HRQoL) in adolescence is analysed. Of special interest is the question, to what extent this relation varies by socio-economic status (SES) and education. Data base is a subsample of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS, n = 6,813, 11-17 years). For the assessment of overweight and obesity, body mass index (BMI) was calculated based on standardised body height and weight measurements. The HRQoL was collected using the KINDL-R-questionnaire, which allows statements concerning a total rating as well as 6 dimensions: physical well-being, emotional well-being, self-worth, family well-being, well-being in relation to friends/peers and school well-being. SES and education are analysed as moderating factors. The results show that obese boys as well as overweight and obese girls have a diminished HRQoL compared to normal weight peers. The analyses according to SES and education suggest that in girls this finding applies for all considered subgroups. Thus, in girls neither SES nor education has a moderating impact on the relation between overweight/obesity and HRQoL. In boys, only SES has a moderating impact on the relation between overweight and HRQoL in favour of the low status group. In terms of the relation between obesity and HRQoL, in boys also only SES has a moderating impact on the analysed relation, but here in favour of the high status group. Altogether, the results show that overweight and especially obese adolescents are affected in their HRQoL, this being almost independent of SES and education. Interventions to improve the HRQoL of overweight and obese adolescents should be independent of SES and education.

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Federal health monitoring deals with the state of health and the health-related behavior of populations and is used to inform politics. To date, the routine data from statutory health insurances (SHI) have rarely been used for federal health monitoring purposes. SHI routine data enable analyses of disease frequency, risk factors, the course of the disease, the utilization of medical services, and mortality rates. The advantages offered by SHI routine data regarding federal health monitoring are the intersectoral perspective and the nearly complete absence of recall and selection bias in the respective population. Further, the large sample sizes and the continuous collection of the data allow reliable descriptions of the state of health of the insurants, even in cases of multiple stratification. These advantages have to be weighed against disadvantages linked to the claims nature of the data and the high administrative hurdles when requesting the use of SHI routine data. Particularly in view of the improved availability of data from all SHI insurants for research institutions in the context of the "health-care structure law", SHI routine data are an interesting data source for federal health monitoring purposes.

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Tobacco smoking, a major cancer risk factor, is very common in Germany as in many other high-income countries. Few studies have assessed the burden of tobacco-associated cancer incidence in the German population. We calculated the proportion of cancers attributable to tobacco smoking to estimate the burden of tobacco-associated cancer in 1999 and 2008. Smoking prevalence was determined from national surveys of a representative sample of the German population in 1998 and 2008-2011, and data on relative risks were obtained from meta-analyses. Cancer incidence for the years 1999 and 2008 was estimated by the German Centre for Cancer Registry Data at the Robert Koch Institute. We estimate that 72,208 incident cancer cases were attributable to tobacco smoking in Germany in 2008, an increase of >6,200 cases over 1999 levels. Among the cases in 2008 were 55,057 cases among men (22.8% (95% CI, 21.3-24.1) of all new cases) and 17,151 cases among women (7.9% (95% CI, 7.21-8.68) of all new cases). The highest proportions attributable to smoking were estimated for cancer of the lung, larynx, pharynx and the lower urinary tract. Tobacco smoking is currently responsible for more than one in five cancer cases among men and nearly 1 in 12 among women. Considering the increasing trends in cancer incidence and, until very recently, rising prevalence of smoking among women, it can be expected that the number of tobacco-attributable cancer cases will rise further.

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BACKGROUND: Individual studies point out that health inequalities decrease in the transitional period from childhood to adolescence. However, there is evidence that this effect can vary depending on the health aspect that is used. The present study analyses this effect for overweight and obesity. METHODS: Representative data was obtained from a subsample (3-17 years, n=14,836) of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) which was conducted by the Robert Koch Institute from May 2003 to May 2006. Body height and weight were measured and body mass index (BMI) was calculated. Overweight and obesity are defined based on gender- and age-specific percentiles of BMI of the German reference system developed by Kromeyer-Hauschild and her colleagues. Socio-economic status (SES) was taken from information about parents' income, occupational status and education. RESULTS: Boys and girls with low SES show the highest prevalence of overweight and obesity in all age groups, those with high SES the lowest. While the results indicate a constant impact of SES on the risk for overweight and obesity in boys, the status differences increase over the age groups in girls. Regarding the whole age range, boys with low SES possess a 2.0-fold increased risk for overweight, and a 2.2-fold increased risk for obesity compared to boys with high SES. Girls from low status group even have a 2.8-fold risk to become overweight, and a 4.4-fold risk to become obese in comparison to the reference group. CONCLUSION: The findings reveal that SES has a significant impact on the occurrence of overweight and obesity in childhood and in particular adolescence. Therefore, the results underline the relevance of early childhood prevention in specific target groups and promotion of a healthy life style.

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OBJECTIVE: There are many studies on health inequalities, but these are rarely combined with cost-of-illness analyses. If the cost-of-illness were to be calculated for the individual status groups, it would be possible to assess the economic potential of preventive measures aimed specifically at people from low status groups. The objective of this article is to demonstrate for the first time the preventive potential by taking the example of diabetes mellitus (DM) from an economic perspective. METHODS: Based on a systematic literature review, the average direct costs per patient with DM were assessed. Then, the prevalence of DM among adults with different educational levels was estimated based on the nationwide survey 'German Health Update' (GEDA), conducted by the Robert Koch-Institute in Germany in 2009. Finally, the cost and prevalence data were used to calculate the direct costs for each educational level. RESULTS: The direct costs of DM amount to about 13.1 billion € per year; about 35% of these costs can be attributed to patients with a low educational level. Thus, their share of the total costs is about 67% higher than their share of the total population. If the prevalence in the group with 'low educational level' (14.8%) could be reduced to the prevalence in the group with 'middle educational level' (7.9%), this would save about 2.2 billion (about 16.5%) € of direct costs. DISCUSSION: The analysis provides a first estimate of the potential savings from an effective status specific prevention programme. However, the direct costs per patient used were only an average for all people with DM, as a breakdown by educational level was not available. Since education can also affect health behaviour and compliance, which are also determinants of cost, the analyses presented here are probably conservative.

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Socioeconomic status (SES) constitutes a central analysis category of epidemiological research and health reporting. As part of the German cardiovascular disease prevention study 1984-1991, a multi-dimensional aggregated index was developed for the purpose of measuring SES. This index continues to be used in numerous studies to this day. For the purpose of health monitoring at the Robert Koch Institute (RKI), the index was fundamentally revised following critical assessment. This article describes the basic concepts underlying the revision and how they were implemented in relation to the "German health interview and examination survey for adults" (DEGS1). In addition, the results of the age and sex-specific distribution of the values of the revised SES index and those relating to the connection with other measurements of socioeconomic status are reported. The results are based on the data of DEGS1 2012 and the German national health interview and examination survey 1998 (GNHIES98). An English full-text version of this article is available at SpringerLink as supplemental.

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Regular physical activity can have a positive effect on health at any age. Today's lifestyles, however, can often be characterised as sedentary. Therefore, the promotion of physical activity and sports has become an integral part of public health measures. The representative data of adults aged 18 to 79 years in Germany obtained from the "German Health Interview and Examination Survey for Adults" (DEGS1) provide an overview of self-estimated current physical activity behaviour. The results show that one third of the adult population claims to pay close attention to reaching a sufficient level of physical activity and one fourth participates in sports for at least 2 h/week on a regular basis. Thus, the percentage of adults regularly engaged in sports has increased compared to the previous "German National Health Interview and Examination Survey 1998". Still, four out of five adults do not achieve at least 2.5 h/week of moderate-intensity physical activity as recommended by the World Health Organisation. Consequently, future individual-level and population-level interventions should focus on target group-specific measures while continuing to promote regular physical activity in all segments of the population. An English full-text version of this article is available at SpringerLink as supplemental.

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The increase in overweight and obesity is a worldwide health problem. The first wave of the "German Health Interview and Examination Survey for Adults" (DEGS1), conducted from 2008 through 2011, provides current data about overweight and obesity among adults in Germany. Within DEGS1, a representative sample of the 18- to 79-year-old population was interviewed with regard to health relevant issues and physically examined (n = 7,116). From measurements of body height and weight, the body mass index (BMI) was calculated, which was used to define overweight (BMI ≥ 25 kg/m(2)) and obesity (BMI ≥ 30 kg/m(2)). Results are stratified for gender, age group, socioeconomic status and region and compared with results from the German National Health Interview and Examination Survey 1998 (GNHIES98) and the National Examination Surveys 1990/92. According to DEGS1, 67.1% of men and 53.0% of women are overweight. The prevalence of overweight has not changed compared to GNHIES98. The prevalence of obesity, however, has risen substantially, especially among men: in GNHIES98, 18.9% of men and 22.5% of women were obese, in DEGS1, these figures were 23.3% and 23.9%, respectively. The increase in obesity occurred especially among young adults. An English full-text version of this article is available at SpringerLink as supplemental.

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Although various tobacco control measures have been implemented in Germany in the recent years, smoking is still widespread and constitutes a considerable health risk for the population. According to the data of the German Health Interview and Examination Survey for Adults (DEGS1), which was conducted by Robert Koch Institute from 2008 to 2011, 29.7% of the 18 to 79-year old population smokes (women = 26.9%, men = 32.6%). The proportion of women and men who smoke 20 or more cigarettes a day amounts to 6.0% and 10.6% respectively. Smoking is mostly widespread among young adults, as well as among persons with low social status who are also overrepresented among the heavy smokers. Comparison with data from previous health surveys indicates that the proportion of smokers has reduced slightly over the last 10 years. An English full-text version of this article is available at SpringerLink as supplemental.

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The analysis focuses on the connection between socioeconomic status (SES) and five health outcomes in the 18 to 79-year-old population of Germany. It uses data from the "German Health Interview and Examination Survey for Adults" (DEGS1) which the Robert Koch Institute conducted in the period from 2008 to 2011 (n=8152). Socioeconomic status is recorded via a multidimensional index which includes information on education attainment, occupational status and household income. The results show that persons with a low socioeconomic status have a self-rated health status which is worse than that of persons with a medium or high socioeconomic status, and that they have diabetes more frequently. They also have a higher risk of depressive symptoms, obesity and physical inactivity. The results illustrate that health chances and the risk of illness are still very socially uneven distributed, thus emphasising the significance of political interventions to reduce health inequalities. An English full-text version of this article is available at SpringerLink as supplemental.

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To study the associations of annoyance to noise and exposure to residential traffic with sociodemographic, socioeconomic and regional characteristics as well as housing conditions, a population-based sample of 7,988 adults 18-79 years of age was studied in the German Health Interview and Examination Survey for Adults (DEGS1). Annoyance to noise and exposure to residential traffic were assessed by self-administered questionnaires. A total of 6.3 % of the participants reported a high to very high exposure to residential traffic noise, 3.7 % to neighbourhood noise and 2.1 % to aircraft noise. An excessive exposure to residential traffic was reported by 21.3 % of the participants. A high annoyance to traffic and neighborhood noise was associated with a lower equivalised disposable income and poor housing conditions. Additionally annoyance to neighborhood noise was associated with low socioeconomic and occupational status. A high annoyance to aircraft noise was only associated with a low equivalised disposable income and living in apartment blocks. Exposure to residential traffic was associated with all investigated indicators. At present in Germany environmental exposures are social unequally distributed and may lead to negative health consequences in social disadvantaged groups. An English full-text version of this article is available at SpringerLink as supplemental.

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