Overview of monitoring instruments

Currently, the systematic monitoring of tobacco use in Switzerland relies almost entirely on data collected during two representative studies at the national level: the Enquête suisse sur la santé[1] (ESS, Swiss Health Survey), which targets the population 15 years old and over, and the Health Behaviour in School-aged Children[2] (HBSC) survey, which addresses students 11 to 15 years old. These studies are the principal sources of data on which the indicators of tobacco use are based in the système de monitorage Addiction et MNT (MonAM) (Monitoring System of Addiction and MNT) of the Federal Office of Public Health (OFSP; OBSAN, 2022[3]). These indicators, which to begin with only partially cover certain key dimensions of smoking behaviour (for example, amount consumed, new products, etc.) are completed using indicators coming from other sources of data with diverse methodological foundations and which were not generally designed to be monitoring instruments (omnibus-type surveys, secondary analyses of survey results which address tobacco use only indirectly) or which are not easily used for this purpose (lack of definition and of compatible measures, major differences in methodology, etc.)

In other words, it is highly regrettable that the monitoring of smoking in Switzerland depends currently on a very limited number of ad hoc indicators, to which are added other lower-quality heterogeneous data. It should be noted that, partially compensating for the lack of quality data, the epidemiological panorama which we describe on our website is founded in part on the older - but relatively detailed - data from Monitorage sur le tabac Suisse [4], which was active from 2001 to 2010, and from the CoRolAR study from the Monitorage suisse des addictions[5], which were conducted between 2011 and 2016 (a synoptic table of the studies used in our epidemiological description is available at the bottom of the page).

Deficiencies of monitoring tools in Switzerland

We also need to underline that, for the purpose of monitoring tobacco use, the data from the Enquête suisse sur la santé and the Health Behaviour in School-aged Children study have their own weaknesses. In use since 1992, the Swiss healthy survey has, from the start, the limitation that it is conducted only once every five years, which makes it impossible to see the progression of tobacco use in our country in a continuous way. The Health Behaviour in School-aged Children study unfortunately has the same drawback, in that it has been conducted at four-year intervals, starting in 1986. The intermittent schedule of these surveys and the logistics involved in conducting and analysing them mean that there is a virtually systematic obsolescence in the findings they produce. In fact, the detailed estimations published from these studies are only available two years after the data are collected. These estimations then become the reference until the publication of the following survey. For example, for the adult population, the detailed estimations of prevalence from the ESS of 2017 were published in 2019, and these will likely be the reference until 2024. The logistics involved in these two studies (ESS and HBSC) also imply that the questionnaires used must be finalised well in advance, which makes it difficult to respond to emerging phenomena. Such logistical imperatives are particularly problematic in an environment where things are constantly evolving, such as with "new tobacco products" - new products which have been appearing and/or replacing each other very rapidly in the past ten years or more. Thus, the monitoring measures currently in use only very partially fulfil their role as warning systems and as means of tracking emerging phenomena. This means that, for example, there is currently a total absence of data about the use of next generation ENDS such as Puff Bars. The absence of data about the use of the latest products or delivery systems makes it impossible to put together an exhaustive overview of current tendencies regarding smoking in our country.

1. Institut universitare de mèdicine social et preventive
2. Schweizer Institut für Sucht- und Gesundheitsforschung
3. Institut für Begleit- und Sozialforschung

Another important limitation in conducting an exhaustive investigation of smoking behaviour comes from the fact that the data gathered from these two studies are limited in quantity, due to the wide array of health-related themes covered. Both the Swiss health survey and the Health Behaviour in School-aged Children study look at health-related behaviours in a broad sense. Thus, they cannot give much space to the theme of smoking. They contain only a small number of questions specifically focused on this. The small proportion of smoking-related questions in these surveys also makes it impossible to exhaustively document current tobacco use and the ways it is changing over time.

Potentially even more problematic, the relatively long periods of time which pass between data collection in the ESS and HBSC means it is difficult to interpret the changes in the available estimations. In particular, it is challenging to know whether the observed variation between two points in time on these measures reflects real changes or just temporary variation, for example due to a context specific to a given year in which the study was conducted. Thus, the tendencies or trends sketched out by the latest results published can only be confirmed - or contradicted - four or five years later.

Combined with the long intervals between data collection, the lack of attention given to tobacco in these studies also makes it impossible to respond quickly and rapidly modify the survey instruments used in function of the short-term changes in tobacco use behaviours (new trends and/or new products, for example). At the same time and for the same reasons, related themes such as smoking cessation or the exposure of the population - and of young people in particular - to marketing, cannot be covered in these studies. It should also be noted that the necessity of these studies providing a "historical" account of tobacco use over time implies that they must continue to use the same measuring instruments as have been used in the past. This necessity reduces the possibility, in both studies, of changing or adding new items relating to other tobacco use behaviours (new products, but also other "traditional" tobacco products). For this reason, for instance, the HBSC study looks essential at the smoking behaviour of 11-15-year-olds in terms of cigarettes; the few items relating to other tobacco products are follow-on questions to the basic questions documenting cigarette smoking.

Many of the limitations relating to the ESS and HBSC studies - problems of time gaps, obsolescence of observations, completeness of questions asked, lack of ability to reflect emerging phenomena, and covering of related themes, to name just a few - were avoided in the past by conducting studies dedicated explicitly to the theme of tobacco use, such as the Monitorage sur le tabac Suisse (TMS[6]), followed by the CoRolAR from the Monitorage Suisse des addictions[7] (a study in which tobacco use was very thoroughly covered, with a subset of subjects utilised and a module of questions focusing on tobacco use).

Regular surveys as a priority

Considering all the weaknesses of the current system of monitoring smoking behaviour in Switzerland, as well as the limitations of the main studies on which it is founded, it appears obvious that that resuming regular observations, with instruments specifically designed to document new developments in tobacco use behaviour and related topics (smoking cessation, influence of the social and economic environment at the individual level) should be a priority. It should be noted that these regular observations should be able to identify and track future developments and changes, even if these phenomena cannot at present be anticipated (whether in terms of new tobacco products or of the development of new methods of consuming products such as CBD and cannabis, which are frequently used in combination with tobacco products). As a result, the resumption of a study like the ones which were active between 2001 and 2016 during the Monitorage sur le tabac Suisse and the Monitorage Suisse des addictions, combined with the systematic and continuous collection of data regarding the sale and marketing of tobacco products, of new tobacco use methods, and of products which will inevitably replace them in the future (such as tobacco substitutes and other items involved in smoking cessation) would make it possible to put in place a real system for the epidemiological monitoring of tobacco use in our country. For example, it also seems essential to understand how and where young people buy the products they use. With the significant increase in sales on the internet (particularly in the context of the COVID-19 pandemic), the way consumers access and buy products have changed, especially for young people. The ad hoc investigation of the way young people access tobacco products should be a particular focus of attention, especially with the future enforcement of the LPTab, which will finally ban sales to minors. In this regard, the monitoring and regulation of sales should also target selling on the internet.

It should be noted that, in light of the changes in smoking behaviour in Switzerland - which develops and stabilises in the youngest age groups - and the flagrant lack of useable detailed data broken down by age group, especially the youngest users, a continuous campaign of observation in the form of an annual survey of these elements appears to be essential for adolescents and young adults. For the rest of the population, however, studies could be conducted every two years.

Ideal monitoring system

In summary, an ad hoc system to monitor tobacco use in Switzerland would ideally include both indicators collected "in real time" (data regarding sales or use of services) and epidemiological estimations available in short time frames and published continuously, especially regarding subgroups of the population which are particularly affected by smoking as well as emerging phenomena. This system should also be compatible with the monitoring model developed for this purpose by the World Health Organization[8] and should be based on a clear theoretical vision[9] and explicitly defined observation criteria[10] (which is not currently the case in Switzerland).

In conclusion, we note that Switzerland's inadequate monitoring problem is not limited to tobacco use but extends to other psychoactive substances and addictive behaviours. In the absence of a quality monitoring system, policy decisions about public health and smoking prevention can only be inadequate as well. Such a monitoring system will certainly have a cost - which nowadays can be reduce by a more intensive use of new technologies - but we believe our country can afford to equip itself with such a system, for all addictions, but especially for smoking, which - it must be remembered - is at the root of half of the social costs related to addiction in this country.

[1] https://www.bfs.admin.ch/bfs/fr/home/statistiques/sante/enquetes/sgb.html; accessed 14.04.2022.

[2] https://www.hbsc.ch; accessed 14.04.2022.

[3] https://ind.obsan.admin.ch/fr/monam/topic/1TAB; accessed 14.04.2022.

[4] http://www.tabakmonitoring.ch/Accueil_fr.html; accessed 14.04.2022.

[5] https://www.suchtmonitoring.ch/fr/page/8.html; accessed 14.04.2022.

[6] http://www.tabakmonitoring.ch/Accueil_fr.html; accessed 14.04.2022.

[7] https://www.suchtmonitoring.ch/fr.html; accessed 14.04.2022.

[8] https://www.who.int/teams/noncommunicable-diseases/surveillance/systems-tools/tobacco-surveillance; accédé le 14.04.2022.

[9] voir par ex. Groseclose, Samuel L.; Buckeridge, David L. (2017): Public Health Surveillance Systems: Recent Advances in Their Use and Evaluation. In Annual review of public health 38:57–79.

[10] Drewe, J. A.; Hoinville, L. J.; Cook, A. J. C.; Floyd, T.; Stärk, K. D. C. (2012): Evaluation of animal and public health surveillance systems: a systematic review. In Epidemiology and infection 140:575–590.

AT Switzerland, September 2022