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Research report
Smoking trends in Switzerland, 1992–2007: a time for optimism?
  1. Pedro Marques-Vidal1,2,
  2. João Cerveira3,
  3. Fred Paccaud1,
  4. Jacques Cornuz1,4,5
  1. 1Institute of Social and Preventive Medicine (IUMSP), University of Lausanne, Lausanne, Switzerland
  2. 2Cardiomet, University Hospital Center (CHUV), Lausanne, Switzerland
  3. 3Faculty of Medicine of Lisbon, University of Lisbon, Lisbon, Portugal
  4. 4Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
  5. 5University Hospital Center (CHUV), University of Lausanne, Lausanne, Switzerland
  1. Correspondence to Pedro Marques-Vidal, Institute of Social and Preventive Medicine (IUMSP), Centre Hospitalier Universitaire Vaudois and University of Lausanne, Bugnon, Lausanne 171005, Switzerland; pedro-manuel.marques-vidal{at}chuv.ch

Abstract

Objective To assess trends in smoking status according to gender, age and educational level in the adult Swiss population.

Methods Four national health interview surveys conducted between 1992 and 2007 in representative samples of the Swiss population.

Results The prevalence of current smokers increased between 1992 and 1997, decreasing thereafter. In 2007, the prevalence of current smokers (32.0% of men and 23.8% of women) was lower than in 1992 (38.4% and 26.7%, respectively). Whereas the prevalence of current + former smoking decreased from 64.5% in 1992 to 59.3% in 2007 among men, it was similar among women during the same period (44.0% in 1992 and 43.9% in 2007). The prevalence of current + former smokers decreased from 47.2% in 1992 to 46.3% in 2007 in the lower education group (no education + primary), from 54.8% to 52.9% in subjects with secondary level education, and from 55.4% to 48.7% in subjects with university level education. The prevalence of current smokers decreased in all age groups. Finally, the amount of cigarette equivalents smoked per day decreased, but the amount of non-cigarette tobacco (alone or in combination with cigarettes) increased for both sexes.

Conclusion The prevalence of smoking has been decreasing in the Swiss population, for both sexes and for most age groups and educational levels between 1992 and 2007. The health effects of the change in type of tobacco products consumed await further investigation.

  • Prevalence
  • surveillance and monitoring
  • tobacco products
  • Switzerland
  • national health survey
  • socio-economic status
  • smoking
  • cross sectional ME
  • epidemiology FQ
  • smoking RB
  • trends

https://doi.org/10.1136/jech.2009.099424

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    Introduction

    Smoking ranks high among public health problems in the world, with an estimated 7.4–9.7 million tobacco-attributable deaths by 2030.1 Information on smoking trends in a country can be helpful in decreasing smoking habits,2 and, in Europe, some general trends regarding smoking status have been reported.3–6 Smoking is more prevalent among lower educated subjects,3 and smoking prevalence has been shown to decline at a slower pace among these subjects than their higher educated counterparts.3 Finally, most smokers begin smoking before 18, and the earlier they begin, the harder it is to quit.7 Thus prevention of smoking-related illnesses has not only to address current smoking behaviours but also the initiation of smoking in adolescence.8

    Smoking has been held responsible for ∼16% of all deaths and 20% of premature deaths (between 25 and 64 years) in the Swiss population.9 However, since the MONICA surveys in the 1980s,10 little has been reported about smoking trends in Switzerland. Several studies conducted at the local level have shown relative stabilisation of smoking prevalence,11 12 but little is known about trends at the national level. Hence, we used national representative data from the Swiss Health Surveys (SHS) to assess smoking trends between 1992 and 2007.

    Participants and methods

    Swiss Health Survey

    Data for the four SHSs were obtained from the Swiss Federal Bureau of Statistics (http://www.bfs.admin.ch). The SHS is a cross-sectional, nationwide, population-based telephone survey conducted every 5 years since 1992 by the Federal Statistics Office of Switzerland under a mandate of the federal government.13 It aims to track public health trends in a representative sample of the resident population of Switzerland aged 15 years and over. To date, the survey has been carried out four times, in 1992, 1997, 2002 and 2007.

    The study population was chosen by stratified random sampling of a database of all private Swiss households with fixed-line telephones. Switzerland has one of the highest coverage of fixed phone lines in the world,1 with over 90% of Swiss households currently estimated to have fixed telephones. The first sampling stratum consisted of the seven main regions: West ‘Leman’, West-Central ‘Mittelland’, Northwest, Zurich, North-Eastern, Central and South. The second stratum consisted of the cantons, and the number of households drawn was proportional to the population of the canton. In some cantons, oversampling of the households was performed to obtain accurate cantonal estimates, and extra strata were used for the cantons of Zurich and Bern. Overall, 29 strata were used. From within these 29 strata, households were randomly drawn and, one member was randomly selected from all members aged 15 years and over within the household. A letter inviting one specific household member to participate in the survey was sent to each sampled household; that person was contacted thereafter by phone and interviewed using computer-assisted telephone interview software to manage dialling and data collection. Face-to-face interviews were organised for subjects older than 75 years. In the case of the long-term absence of a sampled subject, a proxy interviewee was requested to provide answers on behalf of the predefined sampled person (∼2.8% of the sample). Interviews were carried out in German, French or Italian, as appropriate. People who did not speak any of these three languages were excluded from the survey. Other criteria for exclusion were: asylum seeker status, households without a fixed-line telephone, very poor health status and living in a nursing home.14 Four sampling waves were performed (winter, spring, summer and autumn). The participation rate was 71% in 1992, 85% in 1997, 64% in 2002, and 66% in 2007. More details are available at http://www.bfs.admin.ch/bfs/portal/fr/index/infothek/erhebungen__quellen/blank/blank/ess/01.html.

    Data collected

    Three age categories were investigated: 18–44, 45–64 and ≥65 years. Education was categorised as follows: (1) no education completed; (2) first level (primary school); (3) lower secondary level; (4) upper secondary level; (5) tertiary level, which included university and other forms of education above the secondary level. We defined ‘low education’ (categories 1 and 2), ‘middle education’ (categories 3 and 4) and ‘high education’ (category 5) groups. Total income of the household was obtained for surveys 2002 and 2007.

    Participants were categorised as non-smokers if they had never smoked, former smokers if they had quit smoking at the time of the interview, and current smokers if they were currently smoking ≥1 cigarette a day. Data on smoking included the subject's previous and current smoking status as well as the amount of tobacco smoked (number of cigarettes, cigarillos, cigars, or pipes per day). Cigarette equivalents were assessed as follows: one cigarillo (a small narrow cigar) or one pipe = 2.5 cigarettes; one cigar = 4.5 cigarettes; tobacco consumption was categorised into <1, 1–9 and ≥10 cigarette equivalents/day. Tobacco consumption was also categorised into cigarettes only, cigarettes + other, and other (no cigarettes).

    Statistical analysis

    Statistical analysis was conducted using SAS Enterprise Guide V4.1. Results are expressed as number of subjects (percentage) or mean ± SD. Comparisons were performed using χ2 or analysis of variance. A first analysis was conducted using the data from the surveys, and a second analysis was conducted after weighting each subject according to the formula:wih=Hi⋅Nhnhnwhere Nh is the average number of telephone numbers in stratum h (h=29), Hi is the household size (ie, the number of subjects aged 15 years and over living in household i), and nhn is the number of telephone numbers in the sample Sh corresponding to stratum h to the power n (n=sample size in stratum h). Weights were further corrected taking into account the percentage of non-responders by raking ratio estimation.15 Briefly, raking is a way to approximate post-stratification on a set of variables when only their marginal population distributions are known. Raking ratio estimation is based on an iterative proportional fitting procedure involving simultaneous ratio adjustments of sample data to two or more marginal distributions of the population counts. With this approach, the weights are calculated such that the marginal distribution of the weighted totals conforms to the marginal distribution of the targeted population. Statistical significance was considered to be present at p<0.05.

    Results

    The number of participants was 14 521, 12 474, 18 908 and 17 879 for 1992, 1997, 2002 and 2007, respectively. The trends in prevalence of current, former and never smokers according to gender are summarised in figure 1. Overall, the prevalence of current smoking was higher in men than women. The prevalence of current smokers increased between 1992 and 1997 and decreased thereafter, and, in 2007, the prevalence of current smokers was lower than in 1992. The decrease in the prevalence of current smokers was paralleled by an increase in the prevalence of former smokers. In men, the prevalence of current + former smoking decreased from 64.5% in 1992 to 59.3% in 2007, whereas in women it remained relatively constant: 44.0% in 1992 and 43.9% in 2007. Similar findings were observed after weighting (men: 63.8% in 1992 and 58.6% 2007; women: 41.8% in 1992 and 43.3% in 2007).

    Figure 1
    Figure 1

    Trends in prevalence of current, former and never smokers according to gender in Switzerland.

    The trends in prevalence of current, former and never smokers according to educational status are summarised in figure 2. Overall, the medium education group had the highest prevalence of current smokers in all surveys. The prevalence of current smokers increased between 1992 and 1997 in all educational groups, decreasing thereafter. Lower education groups showed the largest decrease in smoking prevalence, followed by higher education groups. An increase in the prevalence of former smokers was observed in the low and medium education groups, whereas there was no such finding in the high education group. The prevalence of current + former smokers decreased slightly from 47.2% in 1992 to 46.3% in 2007 in the lower education group, and from 54.8% to 52.9% in the medium education group, whereas a larger decrease was noted for the high education group: 55.4% in 1992 and 48.7% in 2007. After weighting, the prevalence of current + former smokers remained stable in the low educated group (47.1% in 1992 to 47.3% in 2007), whereas it decreased in the medium (53.5% to 52.9%) and high (55.7% to 47.9%) educated group. When the analysis was stratified by gender, the prevalence of current smokers decreased in all groups for both sexes. The prevalence of former + current smokers decreased among middle educated men and higher educated men and women, whereas a slight increase was found among women in the low and middle education groups (from 38.2% in 1992 to 38.6% in 2007 and from 45.8% in 1992 to 46.2% in 2007, respectively). Similar findings were obtained after weighting (not shown).

    Figure 2
    Figure 2

    Trends in prevalence of current, former and never smokers according to educational level in Switzerland.

    The trends in prevalence of current, former and never smokers according to age group are summarised in figure 3. Subjects aged less than 45 years showed the highest prevalence of current smoking, whereas subjects aged over 65 showed the highest prevalence of former smoking. The prevalence of current smokers decreased in all age groups, whereas the prevalence of former smoking increased among subjects aged 45 years and over. The prevalence of former + current smokers decreased in the group of subjects aged 18–44, whereas it increased in the other age groups. Similar findings were obtained after weighting: the prevalence of current + former smokers decreased in the 18–44-year age group (53.2% in 1992 to 48.9% in 2007), whereas it increased in the 45–64-year age group (55.8% to 57.0%) and remained relatively stable in the >65-year age group (45.2% to 45.3%). When the data were stratified by gender, different trends were observed: the prevalence of current smoking decreased in all age groups in men, whereas it tended to increase among women aged 45–64. Also, the prevalence of current + former smoking decreased in men aged 45–64, whereas it increased in women in the same age group (not shown).

    Figure 3
    Figure 3

    Trends in the prevalence of current, former and never smokers according to age group in Switzerland.

    Cigarettes (alone or in combination with other tobacco products) were the main type of tobacco consumed by current smokers. Men tended to consume tobacco in forms other than cigarettes more frequently than women, and the amount of non-cigarette tobacco (alone or in combination with cigarettes) increased in both sexes (figure 4). Finally, the amount of cigarette equivalents smoked per day decreased in both sexes (from 17 ± 13 in 1992 to 12 ± 12 in 2007 among men, and from 14 ± 10 to 10 ± 9 among women; both p<0.001), but no difference was found between sexes regarding the prevalence of consuming more than 10 cigarettes per day (not shown). Similar findings were obtained after weighting (not shown).

    Figure 4
    Figure 4

    Trends in smoking patterns according to gender in Switzerland.

    Discussion

    There is little information on the association between educational status and secular trend in smoking prevalence in the general population. Education is an important predictor of quitting among smokers.16 The secondary (‘middle’) education group had the highest prevalence of current smokers, probably because it includes subjects doing apprenticeships, a group characterised by high smoking rates as consequence of peer pressure.17 Conversely, the lowest education group showed the strongest decrease in prevalence of current smokers, followed by the highest education group. The decrease in smoking in the low education group was somewhat unexpected, as it has been reported that smoking cessation is less common in this group.17 18 The reasons for this decrease may actually differ according to educational group: subjects who reach a lower level of education have lower total household incomes (age and gender-adjusted total household income (mean ± SE): 5726 ± 171, 7603 ± 75 and 10 026 ± 107 Swiss Francs for low, middle and high educational level, respectively, in 2007; p<0.001). This lower income may be the reason for the decrease in smoking because of the increased cost of tobacco,19 although this has been challenged.20 Indeed, tobacco excise tax has increased greatly over the last 15 years in Switzerland.21 Conversely, the high education group may show a better response to social initiatives to cut down smoking.3 Subjects in this group may also be more responsive to anti-smoking messages or have more contact with exemplary role models regarding smoking prevention and cessation.22 Thus our results indicate that the prevalence of current smoking is decreasing mainly among low and high educated subjects, and that this decrease is probably due to different preventive measures.

    The prevalence of current smoking decreased for both sexes, a trend already reported in the last 30 years in several Western European countries.3 This decrease in smoking prevalence does not confirm previous studies conducted in Geneva,11 which reported a plateau in smoking prevalence through the 1990s. Indeed, smoking was still socially acceptable in Switzerland during the 90s, as illustrated by the refusal by Swiss citizens in 1993 to accept a constitutional initiative to ban tobacco advertising.23 Further, tobacco control levels at that time were relatively low, as illustrated by the lack of any nationwide smoke-free policy and the low level of tobacco tax. Other possible explanations are the fact that the previous study reported data only for one Swiss canton (Geneva) and for a limited period of time (data analysis stopped in 2002), so that the recent trends of decreasing smoking prevalence may have been missed. Men showed a greater decrease in smoking prevalence than women, a trend in agreement with the beginning of stage 4 of the cigarette epidemic model proposed by Lopez et al.24 The larger decrease in men may reflect greater sensitivity to increased mortality from tobacco-related illnesses in men, reported in the early phase of stage 4 of the smoking epidemic model.24 For both sexes, the decrease in the prevalence of current smokers was associated with an increase in the prevalence of former smokers. Similar trends have been reported in Barcelona,25 the USA, the UK and Australia26 and may reflect increased sensitivity to preventive measures directed against smoking. The highest prevalence of former smokers among men is in agreement with a study conducted in the USA, where the cumulative nature of the prevalence of former smokers was reported over time: as US men started quitting smoking earlier than women, the prevalence of former smokers was higher among men.16

    The prevalence of current smokers decreased and the prevalence of former smokers increased with age. Of particular interest is the fact that the prevalence of never smokers increased in the younger age groups, a finding also reported in other countries,27 possibly indicating an effect of primary prevention. Another interesting finding is the different trends of the joint prevalence of former + current smokers according to gender: a decrease in middle-aged men, an increase in women. The increase in smoking among middle-aged women is in agreement with other studies28 29 and suggest that the effects of prevention are bearing their fruits in men, whereas in women a cohort effect may be operating, as the high numbers of women who started smoking in the nineties are getting older.30

    Mean tobacco consumption by smokers decreased substantially in both sexes, a finding also reported elsewhere.31 The decrease was somewhat greater for men; in 2007, more women reported smoking at least one cigarette equivalent per day than men. Furthermore, men more often consumed other (non-cigarette) tobacco products, a finding already reported in other countries.32 33 Although no precise information on the type of tobacco product consumed was available, a likely hypothesis is that, owing to the increasing cost of cigarettes and other ‘classic’ tobacco products, smokers are progressively turning to cheaper forms of tobacco such as rolling34 or chewing tobacco, or fashionable forms such as narghile (waterpipe smoke).33 As there is evidence that rolled cigarettes can contain two to three times as much nicotine and tar as manufactured cigarettes35 36 and that waterpipe smoking is related to a variety of life-threatening conditions, including pulmonary disease, coronary heart disease and pregnancy-related complications,37 specific public policy strategies should be implemented against these new smoking fashions.

    Our data also suggest that the comprehensive tobacco prevention programme issued by the Swiss Federal Office of Public Health that focuses on specific interventions, cooperation between partners for tobacco prevention, and programme coordination and management has been playing a role in this secular trend.21 Finally, albeit Switzerland has signed the WHO Framework Convention on Tobacco Control, it has not yet ratified it. The Swiss authorities have decided to ratify the treaty only after modifying laws to be concordant with it. This objective has been scheduled for 2013–2014.

    This study has some limitations that should be considered. For instance, the survey methodology included a direct random sampling of one person among those living in the household. If the sampled person declined participation, no other person from the household was selected. Hence, selection biases are likely to occur (availability at home, size of the household, readiness to answer, etc). However, proxies represented only 2.8% of the overall sample, and it has been shown that smoking data obtained from proxies are reliable and can be used in epidemiological studies.38–40 Hence, it is unlikely that a large systematic error is distorting the results. Also, no data on subjects aged <18 years were considered. This was done because adolescents questioned about their smoking habits by phone in a home setting may be reluctant to report their true smoking habits, leading to a possible reporting bias. Finally, although the decreasing participation rate may be a concern, it is still high compared with other studies,41 and it has been shown that the magnitude of the non-participation bias is not proportional to the percentage of non-participants.42 The major advantages of this study are that it is based on nationally representative samples, and that the data have been collected using the same methodology throughout, enabling the calculation of trends.

    In summary, the results indicate that the prevalence of smoking in the Swiss population is decreasing for both sexes, all educational and most age groups. The shift in the types of tobacco products consumed awaits further investigation.

    What is already known on this subject

    In Switzerland, local surveys indicate that smoking prevalence has stabilised, but nationwide trends are lacking.

    What does this study add

    The prevalence of smoking is decreasing in the Swiss population for both sexes, all educational and most age groups; there is a shift regarding types of tobacco products consumed which should be further investigated.

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    Footnotes

    • Competing interests None.

    • Provenance and peer review Not commissioned; externally peer reviewed.