Adam Whalen ISP

Smok i n g i n Sw i t z e r l a nd : A n a l y s i s o f Y o u t h P e r c e p t i o n o f C i g a r e t t e U s e

Adam Whalen SIT Switzerland: Global Health and Development Policy Fall 2013

TABLE OF CONTENTS

ABSTRACT .......................................................................................................... 3

INTRODUCTION ................................................................................................... 3

METHODOLOGY .................................................................................................. 7

RESULTS ............................................................................................................. 9 Survey Results .......................................................................................................... 12

DISCUSSION ...................................................................................................... 17 Possible Intervention Program ................................................................................ 20

CONCLUSION AND SUGGESTIONS ................................................................ 22

BIBLIOGRAPHY ................................................................................................. 24

APPENDICES ..................................................................................................... 26 Appendix I: ISP Work Journal .................................................................................. 26 Appendix II: Survey Questionnaire, English .......................................................... 28 Appendix III: Survey Questionnaire, French .......................................................... 31

ACKNOWLEDGEMENTS ................................................................................... 34

Adam Whalen SIT Independent Study Project – Fall 2013 3 Smoking in Switzerland: Analysis of Youth Perception of Cigarette Use Smoking in Switzerland: Analysis of Youth Perception of Cigarette Use

ABSTRACT

Smoking in Switzerland is a growing concern. Even as rates among

smokers have more or less stopped increasing over the past few years, high

rates of people are still smoking cigarettes, including many young people.

Because of the health risks associated with smoking, it is critical to reduce the

overall prevalence of cigarette users in Switzerland. Interventions aimed at

preventing youth from starting to smoke in their teenage years can be effective in

curbing this high rate. Through determining the reasons for which youth start

smoking cigarettes, a successful and pertinent intervention plan can be

developed to prevent these youth from adopting this destructive habit.

INTRODUCTION

Tobacco use is one of the leading causes of preventable death in the

world today (WHO.int, 2013). Cigarette smoking is a serious epidemic that

affects millions of people across the globe, and continues to cause disease and

kill smokers and non-smokers alike. In 2011, tobacco use was responsible for

nearly 6 million deaths, and it is projected that total deaths due to tobacco for the

21st century will reach 1 billion (Ericksen, 2005). Cigarette smoke is a leading

cause of a plethora of diseases, ranging from osteoporosis to blindness, and all

four of the leading non-communicable diseases: cardiovascular disease,

diabetes, cancer, and chronic respiratory disease.

The World Health Organization (WHO), in their 2013 Global Tobacco

Epidemic Report, stated that 19% of the Swiss population smokes daily, which

leads to severe health consequences for both the users and their neighbors in

the community at large (WHO 2013). Young people are most at risk to develop

bad smoking habits early on, which they will carry throughout their lives. Also,

older populations who have been smoking for their whole lives are far less likely

to quit on their own, if at all (Marques-Vidal, 2011). In order to design an

appropriate intervention program to combat high rates of smoking, the cultural,


economic, and social reasons for the popularity of smoking must first be

acknowledged and evaluated.

In 2003, the WHO released the Framework Convention on Tobacco

Control (FCTC), which was a huge piece of global health legislation that sought

to prevent the further spread of the tobacco epidemic. This convention

established a framework for nations to control tobacco and reduce the negative

health impacts that it has on a national, regional, and international level, including

measures to reduce both the supply and demand for tobacco, scientific

cooperation, and communication of tobacco-related concerns, among many

others. The document was drafted and approved at the WHO headquarters in

Geneva, and later sent to New York for a one-year ratification and signature

period. Over 173 parties have ratified and signed the FCTC, meaning that they

both agree and support the document (ratification) and pledge to follow it

themselves (signature). However, both the United States and Switzerland have

ratified but failed to sign the document, making them two of only ten countries in

the world to have done so (Ericksen, 2005). In addition, only ten other countries

have neither signed nor ratified the document, still making it one of the most

widely accepted unilateral global documents held in place to date.

In Switzerland, cigarette smoke is of a particular concern as roughly one

quarter of the population smokes. Not only is that concerning on its own, but 35%

of boys and 30% of girls ages 13-15 smoke as well. The rate at which young

people are smoking in Switzerland is alarming, especially since it is considered

by many other standards to be one of the healthiest countries in the world.

Because cigarettes are so addicting, the earlier a person starts smoking, the

more likely they are to become a lifelong smoker. This is strongly associated with

higher risks to develop potentially life-threatening diseases that could be easily

prevented if the person had not smoked cigarettes.

Smoking is responsible for numerous health-related concerns. Primary

smokers put themselves at an increased risk for many different types of cancer,

chronic disease, and many other potentially life-threatening illnesses. The cause

of these diseases can be found in the chemicals released when cigarettes are


burned in smoking. Some of the chemicals found in cigarette smoke include

carbon monoxide, lead, hydrogen cyanide (the lethal agent in mustard gas), and

toluene and acetone, both strong chemical solvents. Also included in those

harmful chemicals is nicotine, the addictive substance found in cigarettes that

creates a dependency of the user on smoking, making it both more difficult to quit

and more damaging to the smoker’s health, as the person exposes himself or

herself to more harmful chemicals over a longer period of time.

Smoking is a serious public health concern because it is very dangerous

not only to smokers but also to those around them, due to the harmful effects of

secondhand smoke. However, it is also of particular interest because it is a

largely preventable cause of disease, yet affects so many people worldwide. In

the past several decades, there has been a significant push in marketing towards

cessation products, such as nicotine patches, gum, and other methods used to

get people to stop smoking. As effective as these cessation strategies may be,

the harmful heath repercussions felt by smokers can continue even after they

have stopped smoking. In many cases, their prior tobacco use has already

caused irreparable damage. This is why prevention is a preferable method to

curbing tobacco-related deaths and illnesses, as the only real way to prevent

smoking-related disease is to not smoke at all. While increasing rates of

cessation is certainly an effective way to reduce the prevalence of current

smokers, the incidence of smokers remains largely unchanged, therefore

continuing to create more health problems particularly among youth, through

both primary and secondary smoke inhalation. By preventing people from picking

up smoking in the first place, we can reduce the incidence of smokers, therefore

gradually reducing the prevalence over time, while also helping current smokers

to quit.

Because prevention is such a more successful and preferable anti-

smoking strategy, it is important to focus on the population of people who would

benefit most from such a plan. It has been demonstrated that older smokers

often do not wish to quit, for several reasons including the notion that they do not

believe it lends any benefit to stop at an advanced age after having been


smoking for a substantial period of time (Marques-Vidal, 2011). Therefore, it is

most effective to try to get younger people to quit smoking, as the earlier they

start trying to stop, the more likely they will be successful; in the same line of

thought, focusing on younger populations, who are more likely to start smoking

and become addicted faster, for prevention strategies may prove to be not only

more effective in terms of reducing the number of smokers in the population, but

also from a public health standpoint by reducing the overall prevalence of the

negative health effects associated with smoking.

Many prevention programs are already in place that target younger

populations in order to stop youth from picking up this dangerous behavior. Some

involve giving monetary rewards to classrooms in exchange for remaining

smoke-free, while others promote awareness of the dangers of smoking through

education and by printing graphic labels on cigarette boxes showing the effects

of disease. While these have proven to be mildly successful, an important factor

is missing from the equation. In order to prevent young people from picking up

smoking, it is crucial to first learn about the reasons for why they may be smoking

in the first place. By understanding the root cause of the desire to smoke, it may

be easier to design an intervention-based approach that will effectively reduce

the incidence of smoking in Switzerland.


METHODOLOGY

This project was developed as a result of a combination of literature

research and a survey administered to university level students in Switzerland.

Literature research consisted of peer-reviewed articles, fact sheets, publications,

organization websites, and other credible informational sources. The articles and

print/online materials provided statistical data about the smoking epidemic

worldwide as well as in Switzerland, and gave a focus to the subject of research

where holes in the established information could be found. The articles were

located using online databases such as PubMed or Biomed Central.

The main focus of the paper is on the survey conducted in the French-

speaking region of Switzerland, including the Geneva, Vaud, Neuchatel, and

Fribourg cantons. The survey asked questions regarding the personal smoking

habits of the subjects, as well as their connection to smoking through peers,

family, etc. It also focused on the subjects’ perception of smoking in terms of risk,

why someone would consider starting to smoke, and what they think when they

see someone young smoking. This survey provides data that serves to answer

the research question of what young people think about smoking and why they

start, serving to fill the holes in current research. The survey was sent out

electronically to several different institutions of higher learning, including the

universities of Fribourg, Geneva, Lausanne, Neuchâtel, the EPFL, and Webster

University Geneva. Several of these schools responded that they would be

unable to forward the survey onto students for various reasons; personal

connections to students from the EPFL and University of Lausanne proved to be

the most successful in disseminating the survey to their peers.

The survey was administered in both English and French to increase the

potential reach of the survey to students who may speak either language. The

survey was created through a paid subscription to FreeOnlineSurveys.com, and

was disseminated to Swiss students above the age of 18 mainly through email

and Facebook. The survey questionnaire was submitted to the Internal Review

Board (IRB) for review, and was approved by SIT for use in this research project.


Results were collected and analyzed through both the survey hosting website,

and through Microsoft Excel manipulation. All graphs and figures were personally

developed.


RESULTS

Previously conducted research is very informative as to the perception of

smoking by Swiss youth. A study conducted by the group Tobacco Monitoring

Switzerland interviewed students aged 14 to 19 and asked them about their

smoking habits and opinions about smoking. When asked for their opinions about

the pros of smoking, students responded most that it had become a habit (68%),

it helps them cope with stress (66%), and that they enjoy the taste of smoking

(61%). For reasons why not to smoke, respondents answered with concerns

about health (95%), fear of addiction (89%), and because it’s expensive (80%).

83% of non-smoking students also mentioned the bad smell from smoking as a

reason to abstain (Radtke, 2011).

Students were also asked to rate the dangerousness of smoking, as well

as other substances such as heroin, cocaine, marijuana, alcohol, and coffee.

Since 2001, the perceived danger of smoking has declined somewhat, although

not nearly to the same degree as have other substances. Yet overall, students do

not see smoking as that dangerous, which is a concern from a prevention

standpoint (Radtke, 2011). If students do not perceive tobacco to be harmful,

they will be more likely to use it.

One issue that persists in Switzerland is that of underage minors

purchasing cigarettes. In Switzerland, there is no national law dictating the age at

which one may purchase a pack of cigarettes; the age restriction is managed

individually by the canton, similar to much else in the country. However, the age

varies from canton to canton: for example, the canton of Vaud set their age limit

at 18, but the canton of Geneva has set their age limit at 16. Regardless of the

actual age of restriction, many stores selling tobacco products do not enforce this

law by checking IDs and refusing sale to youth under the posted age restriction,

as 45% of 14-15 year olds in Switzerland buy their own cigarettes (Radke, 2011).

Another study sought to determine the underlying psychological reasons

for why young people smoke. The Swiss Federal Office of Public Health

(SFOPH) published a report in 2006, consisting of several studies on the risk


behavior of adolescents, ranging anywhere from tobacco use to theft and

vandalism. The report found that youth who tend to be more hedonistic were

more likely to smoke; conversely, those who were less hedonistic were more

likely to reduce or retire their smoking habits (Brodbeck, 2006). While this

information is interesting and useful when looking into the psychological

behaviors of smokers, it is not very practical from a public health standpoint, as it

is difficult to prevent or intervene against a personality or psychological tendency.

An important focus in the prevention of smoking, particularly among youth,

is the ban on tobacco advertising. As mentioned earlier, even though Switzerland

is a ratifying party to the WHO FCTC, it has yet to sign the document, meaning

that it is merely behind these pledges in word and not in action. This is

attributable to the very strong hold that the tobacco industry has in the interests

of the nation. Lausanne, situated at the northeast shore of Lake Geneva in the

Vaud canton, is the world headquarters for Phillip Morris International, the largest

non-governmental tobacco company in the world by volume, selling 831 billion

cigarettes in 2007 (Associated Press, 2007). Also, British American Tobacco, the

second largest international tobacco company in the world, has its Swiss

administrative offices located in Lausanne. The presence of these massive

multinational tobacco corporations within the country creates a demonstrated

conflict of interest for tobacco prevention strategies.

The WHO Report on the Global Tobacco Epidemic, 2013 edition focuses

on the advertisements and marketing strategies of major tobacco companies and

how these must be constrained to reduce the prevalence of smokers in the world.

It emphasizes the need to reduce marketing campaigns directed towards children

specifically, saying that “one third of youth experimentation with tobacco occurs

as a result of exposure to tobacco advertising, promotion and sponsorship”

(WHO, 2013).

Looking closer at the data, it is obvious that Switzerland has serious

ground to make up in terms of managing tobacco promotion in public life. While

there is a ban on national and international radio and television tobacco

advertisements in Switzerland, there are no advertising bans elsewhere, such as


on billboards, in newspapers and magazines, or on the Internet. However, each

canton does prohibit the placement of outdoor advertising of tobacco products,

such as billboards; this is unfortunately not always followed, as one may see

poster ads promoting Marlboro cigarettes or something of the like at as common

a place as any train station. There are no bans at all on tobacco promotion or

sponsorship, such as product placement, appearance of tobacco products and

use in TV/film, sponsored events, and others. Switzerland also does not ban

other forms of sponsorship or promotion such as anti-tobacco messaged

accompanying media-related tobacco use depiction, or cigarette vending

machines. The year in which Switzerland achieved the greatest levels of tobacco

monitoring was in 2010, so clearly there is room for improvement (WHO, 2013).


Survey Results

Figure 1: Histogram showing subjects’ personal smoking habits with regards to frequency in percent (%). Original survey question: “Do you currently or have you ever smoked cigarettes?” Data collected via survey responses. Total does not equal 100% because of rounding.

Figure 2: Histogram depicting distribution of age at first cigarette smoke by smoking subjects surveyed, in percent (%). Original survey question: “If you smoke, how old were you when you first smoked a cigarette, more than a puff?” Data collected via survey responses.

16

9 14

17

43

0 5 10 15 20 25 30 35 40 45 50

Daily Weekly Monthly Not currently Never

Percent (%)

Frequency of Cigarette Smoking

Personal Smoking Habit

3

10

16 13

29

16 13

0 5 10 15 20 25 30 35

12 13 14 15 16 17 18

Percent (%)

Age (years)

Age of Smoking Respondents at First Cigarette Smoked


Figure 3: Histogram depicting the distribution of the reasons subjects’ gave for starting smoking initially, by percent (%) of responses for each. Original survey question: “If you smoke, what are the reasons that you chose to start? If you do not smoke, what do you believe your peers’ reasons for starting are?” Respondents were able to select more than one answer, therefore resulting in total responses above 100% across the range of responses. Data collected via survey responses.

In total, the survey rendered about 70 responses from Swiss students

around the French-speaking region of Switzerland. Demographically speaking,

89% of respondents were between ages 18 – 20, and 63% of the subjects

surveyed were male. The survey mandated that all respondents be at least 18

years of age, and the majority of those who responded to the survey were from

the first several years of university study in Switzerland, so many of the

respondents were from this age group. In addition, students were asked whether

they were natural-born citizens of Switzerland, so as to ensure that the results

from the survey were from people actually from the population of interest, that

being Swiss university students. However, the phrasing of the question was

slightly different in English and French, due to translation error, and so the results

from this question are unreliable and are therefore not being considered.

Students were asked about their typical smoking habits, so as to gain

knowledge of the general spread of this behavior among this particular

population. As described in Figure 1, subjects were asked the following question:

“Do you currently or have you ever smoked cigarettes?” (In French, “Fumez-vous

20

62

42

28 30

13 9

0 10 20 30 40 50 60 70

Taste Social connection

or interaction

To ease stress

To have a good time

Because it makes you look cool

To seem older or more mature

Other

Percent (%)

Reasons Provided

Reasons for Starting Smoking


des cigarettes actuellement où avez-vous toujours fumé?”) The majority of

respondents (43%) chose “No, never” (“Non, jamais”), and 17% said “Not

currently” (“Non, pas actuellement”), meaning that they had smoked in the past

but either had quit smoking or smoked less than once per month. 16% of

subjects reported smoking daily, 9% weekly, and 14% monthly. The 16% that

smoke daily could be associated with an addiction to smoking, whereas the latter

two frequencies of weekly and monthly smokers may be harder to explain.

To get another look at the personal smoking behavior and perception of

smoking by smokers, respondents were asked to think about their personal

smoking habits with regards to quitting smoking: “If you do smoke, have you ever

considered quitting?” (“Si vous fumez, avez-vous pensé arrêter de fumer?”) Most

people (72%) responded with “I do not smoke” (“Je ne fume pas”), 7% said they

were looking to quit within the next month, and 3% said they were looking to quit

within the next 6 months. However, 13% said that they plan to quit sometime in

the future yet not now, and 4% had no thoughts about quitting at all.

Subjects were then asked about the first time they smoked. The original

question is: “If you smoke, how old were you when you first smoked a cigarette,

more than a puff?” (“Si vous fumez, à quel âge fumez-vous une cigarette pour la

première fois, plus que une bouffée?”) When examining Figure 2, containing the

data with regard to the earliest age at which a subject smoked a cigarette, one

may be surprised with both the responses and the rate. For the latter, the data is

somewhat skewed on account of the small sample size. Where the graph shows

3% of those surveyed having smoked their first cigarette at age 12, there was in

fact only one respondent for whom this was reported. Here, we see the issue

with a sample population of only 70 people.

Nonetheless, the idea that people had their first smoke of a cigarette at

ages 12, 13, even 14 is certainly shocking, especially coming from a non-Swiss

or non-European background. The majority of respondents said that their first

smoke was between the ages of 14-18, with the highest rate being at age 16

(29%). The graph is slightly skewed right, as more people begin to smoke later in

their teenage years than earlier, but still some smokers start quite early in life.


There were no responses given that placed the age of their first smoke beyond

the age of 18.

Often times, the influence of those closest to the individual have the

greatest impact on their behavior. Students were asked about the smoking habits

of both their close friends and immediate family: “Do any members of your

immediate family currently smoke, or have they during your lifetime?” (“Il y a t’il

quelqu’un de votre famille immédiate qui fume, actuellement ou tout les

temps?”), and “Do any of your close friends smoke, or have they ever since you

have known them?” (“Il y a t’il quelqu’un parmi vos amis proches qui fume,

actuellement ou tout le temps?”) Subjects reported that 41% have a family

member currently smoking, and a staggering 86% have a close friend that

currently smokes. It is notable that 17% of family members are reported as

having smoked before, but not currently, suggesting that they have quit the habit

for one reason or another. It is also interesting to see that while only 39% of

those surveyed smoke currently, 86% of them have a friend that smokes.

The most important question on the survey was that regarding the reasons

for which the subjects started smoking: “If you have ever smoked, what are the

reasons that you chose to start? If you do not smoke, what do you believe your

peers’ reasons for starting are?” (“Si vous avez déjà fumé, quelles sont les

raisons pour lesquelles vous avez commencé à fumer ? Si vous ne fumez pas,

selon vous quelles sont les raisons pour lesquels vos amis fument-ils?”) The

subjects were given several options to select from, as shown in Figure 3.

Subjects were able to select as many answers as they wished, to give a

comprehensive view of their view on this topic. The most commonly selected

reasons were “social connection/interaction” (“lien ou interaction sociale”) at

62%, and “to relieve stress” (“pour soulager le stress”) at 42%. These two

responses will be focused on most heavily. Among the other answers, “other”

(“autres”) was an option and received a few responses. These included ideas

such as curiosity, to rebel, use in conjunction with alcohol, to help diet, and also

to be able to have extra breaks at work.


Subjects were also asked some questions regarding their perception of

smoking as a behavior in general. For one question, students were asked, “What

do you think when you see a peer smoking?” (“Que pensez-vous quand vous

voyez quelqu’un de jeune fumer?”), and their responses were divided up into

three general categories. 62% said that it was a shame, sad, not good, any other

emotions along those lines. 18% referenced health concerns towards the

smoker, such as “he will get cancer,” and 12% responded with indifference, or

that they saw the behavior as normal or not a big deal.

Subjects were then asked to rate their perception of smoking in terms of

health concerns: “Do you think that smoking is a serious health

concern?” (“Pensez-vous que la fumée est une préoccupation grave de la

santé?”) 92% of respondents reported smoking as “very serious” (“très grave”) or

“somewhat serious” (“assez grave”), and only 1% of those surveyed gave

smoking a health rating of “not very serious” (“pas très grave”).

The final survey question sought to determine how dangerous students

perceive smoking to be. “On a scale from 1 to 5, 1 being the lowest and 5 being

the highest, how dangerous a behavior do you think smoking is?” (“Classez de 1

à 5, si 1 est le plus bas et 5 et le plus haut, comment classeriez-vous le risque de

la santé du fumeur?”) 13% of students responded with a rating of 5, 56% rated a

4, 22% rated it a 3, and only 9% rated it a 2 in terms of danger.


DISCUSSION

As mentioned above, the understanding gained from learning more about

the perceptions and beliefs of youth about smoking can be useful for determining

possible future interventions to try to reduce the incidence of smokers.

Fortunately, according to the survey results, the number of people that do not

smoke currently or never have is high, at 60%. Knowing that the sample

population consisted of mainly university-level students, this is not surprising. It is

often found that those with a higher education level are less likely to indulge in

vice behaviors, such as smoking (Fernandez, 2006). This “student-bias” could

possibly explain why there is such a low rate of smokers among the population

surveyed. Unfortunately, this cannot be proven through this survey alone;

because the sample population consists of only students and has no other

groups such as apprentices or full-time employees of the same age, there is no

further information to which to compare the data, so as to confirm this analysis.

This low rate of smoking could also be because the subjects are aware of the

risks of smoking, due to their higher education level, and therefore choose not to

engage in this behavior. This is reflected in their overall negative view of smoking

as a behavior, which will be further discussed later.

Of the subjects that do smoke, only 16% smoke daily, suggesting either a

physical or habitual addiction to the behavior. For the groups that smoke less

frequently, 8% weekly and 14% monthly, their habits may be linked more directly

to the two main reasons given for starting smoking in the first place: a means to

relieve stress, or a way to achieve social interaction or connection. Smoking is

also often associated strongly with drinking alcohol, which could be another

explanation for why students would smoke only on a weekly or monthly basis.

Respondents who do smoke mentioned that they started smoking very

early in life, as shown in Figure 2 and Appendix IV. The majority reported having

their first smoke around the age of 16, with the youngest having started at the

age of 12. This trend of smokers starting early is concerning from a public health

standpoint, as the longer that people are exposed to smoking, the risk of


developing smoke-related illness increases. Therefore, the earlier that a person

starts smoking, the greater are their risks of developing life threatening diseases

such as cancer. It is likely that the reason why people start smoking so early in

life is because of the direct influence of the behavior of others on them. People

who begin smoking early in life can be associated with family members who

smoke (41% of those surveyed) as well as close friends who smoke (86% of

those surveyed). If the person grows up always around smoking, they may see

this behavior as acceptable or normal and therefore will adopt it themselves, or at

least at an earlier age than otherwise.

In the same line of thought, it is interesting to note that the students

surveyed reported themselves as smoking far less than their friends (39% of

subjects currently smoke, 86% of friends currently smoke). This could be

because of several things. It is possible that the students know more about the

risks of smoking, and choose not to indulge, whereas their friends either do not

know the risks or simply choose to ignore them. It is however, also possible that

the high rate of friends that smoke is simply due to the fact that the subjects may

have a large amount of friends, and the odds are likely that they will happen to

know someone who smokes. Regardless, the numbers are still incredibly high for

those who know someone who smokes, and because the main reason for

starting smoking was determined to be social interaction or fitting in with friends,

it is possible that these smokers are having an effect on the behaviors of their

non-smoking friends.

Overall, it seems that the students surveyed had a generally negative view

of the behavior of smoking. When asked about their perception of others

smoking, the danger of smoking, and how serious the health risks of smoking

were, many reported thinking that it was overall a negative behavior with bad

health outcomes, making it not worth it to participate. Many of the smokers asked

about their intentions to quit also reported having thought about it at least

somewhat, thereby acknowledging that it is a bad or unhealthy habit. This

suggests that overall, many people understand the risks of smoking, and some

therefore choose not to take them. Additionally, this points to the idea that in


terms of an intervention strategy, awareness and education about the risks of

smoking may not be effective, as it appears that most people already understand

the risks that they take when they smoke, at least to some extent, and just

choose to take them anyway.


Possible Intervention Program

As many students and youth seem to understand the risks they take when

smoking, awareness interventions may not be very successful in reducing the

incidence of young smokers, as stated above. It may be more beneficial to create

smoke-free environments for socialization and stress-relief, where students can

come be with one another and have fun without the influence of tobacco.

This particular intervention strategy would resemble a youth group,

specifically for people around the ages of 14-18, which is when the majority of

smokers reported starting the habit. Also, these ages are the most susceptible to

the negative influences of peers, so creating a group isolated from tobacco may

prove to keep it out of their lives as well. By creating a place to alleviate stress

and socialize with peers, the two main reasons for starting smoking are

effectively negated.

This “youth group” could consist of a place to come and spend time,

organized trips to various events, and other similar activities, and can even be

tied to each school that participates. The group would be best facilitated by youth

as well, of a slightly older age than the members themselves. This is because

teenagers of that age are unlikely to participate or respond to activities if they are

suggested or managed by adults, simply because of the fact that teenagers

generally like to rebel against perceived authority. I would suggest that university-

age students be the ones to facilitate the programs through the group, as they

will be able to relate closely to the members as well as having a sense of

authority that is less likely to be opposed, if applied appropriately.

This youth group will have neither a religious nor a civic affiliation tied to it;

it will simply be a fun way to get away from tobacco in a safe environment. Many

universities in the United States actually have very similar programs to this in

place, in the form of student programming groups. Here, a group of students

organize events for other students to participate in, and it is sponsored through

the university itself. These programs are not often, if at all, promoted as being

ways to avoid the influence of alcohol, tobacco, or drugs, yet they are often


serving that purpose specifically. For example, if a student programming group

organizes a chartered bus trip to see a movie, it may be stated that no alcohol or

drugs are allowed on the trip, but the group itself is not outwardly focused on

reducing alcohol or drug use. In this same way, this intervention group will not

publicly mention that it is a means to avoid the influence of tobacco, but it will

hopefully serve to do just that.


CONCLUSION AND SUGGESTIONS

As with any study, there are some flaws and shortcomings that can be

improved in future research projects of the same subject. To strengthen the

findings of this study, it would be beneficial to include apprentices and employed

people of the same age in the survey population along with university students,

so as to compare the three groups of people and their smoking habits and

opinions. Also, it would help to survey younger populations of people, for

example from ages 14-18, so as to confirm the results and establish a base for

what these aged people think about smoking. It would be much more helpful to

get a larger population size; it is hard to get an accurate view of the population

when there are only 70 respondents. One could focus future research on not just

cigarettes but all types of tobacco, including cigars, hookah, smokeless tobacco,

etc. However for Switzerland specifically, cigarettes are most commonly used,

which is why this study focused solely on that form of tobacco use. Future

studies would also do well to utilize advanced statistical analysis software to

better delve into the data given. For example, being able to separate non-

smokers and smokers into separate groups would have been helpful, but with the

statistical methods and time available, this was impossible.

Some possible sources of bias could also have influenced the data in

some way. On the survey, there was no question asking about the

school/education level of the respondent. Originally, the survey was designed

specifically for college students alone, and was sent directly to universities for

their students to answer, so there was no apparent need to double check if the

respondents were university students. However, after the aforementioned lack of

response, this could be a source of bias, because there is no way to check

whether the respondents were actually from universities as presumed. On a

similar note, because the surveys were sent out solely through personal

connections made in Switzerland, there could be bias associated with the fact

that there was no way to ensure that the sample was random. However, because


there was no other option to get the survey out to the population of interest, this

is a bias that had to be accepted.

One question on the survey asked about Swiss citizenship, to ensure that

the subjects were actual Swiss students as opposed to internationals. The

question should have been worded more closely to “Are you a Swiss citizen?” In

English it was written as, “Are you a natural-born citizen of Switzerland,” whereas

the French version was “Etes-vous né en Suisse” which translates to “Were you

born in Switzerland?” This is not exactly the same question, and due to the

translation error, the data appeared inconsistent and thus was removed from

analysis. This can likely be more or less alleviated when surveying younger

populations, as far more of the students in middle and high school are likely to be

Swiss citizens than university students who may come from an international

background.

It is clear that cigarette smoking is a problem in Switzerland, especially

among youth. Students likely begin smoking due to the normalization of this

behavior for them through the example set by family members or close friends,

as a stress coping mechanism, or to gain social interaction, among other

reasons. Because extended exposure to smoking increases the risk of

developing tobacco-related illness, it is crucial to prevent youth from starting this

habit as much as possible. Some interventions targeting the most at-risk group

for starting smoking (ages 14-18), that also effectively deal with the main reasons

for starting smoking may be effective in the prevention of smoking and an overall

reduction in both incidence and prevalence of this destructive behavior.


BIBLIOGRAPHY

Ericksen M, Mackay J, Ross H. The Tobacco Atlas. 4th ed. Atlanta, GA: American

Cancer Society; New York, NY: World Lung Foundation; 2012. Also available at

ww.TobaccoAtlas.org.

Brodbeck, J., Matter, M., Artho, S., Röthlisberger M., Moggi, F. (2006).

Wohlbefinden, Belastungen und Gesundheitsverhalten bei jungen Erwachsenen :

Eine Längsschnitt-Studie. Final Report. Universitätsklinik für Psychiatrie Bern.

Kuntsche, E. (2004). Progression of a general substance use pattern among

adolescents in Switzerland? Investigating the relationship between alcohol,

tobacco, and cannabis use over a 12-year period. European addiction research,

10 (3), pp. 118--125.

Marques-Vidal et al.: “Prevalence and factors associated with difficulty and

intention to quit smoking in Switzerland.” BMC Public Health 2011 11:227.

Radtke, T., Keller, R., Krebs, H. & Hornung, R. (2011). Der Tabakkonsum

Jugendlicher und junger Erwachsener in den Jahren 2001 bis 2010.

Tabakmonitoring – Schweizerische. Umfrage zum Tabakkonsum. Zürich:

Psychologisches Institut der Universität Zürich, Sozialund.

Gesundheitspsychologie.

WHO (2013). WHO Report on the Global Tobacco Epidemic, 2013. [PDF]. World

Health Organization.

Who.int (2013). WHO | The top 10 causes of death. [online] Retrieved from:

http://www.who.int/mediacentre/factsheets/fs310/en/index.html [Accessed: 27

Sep 2013].


Fernandez, E., Schiaffino, A., Borrell, C., Benach, J., Ariza, C., Ramon, J.,

Twose, J., Nebot, M. & Kunst, A. (2006). Social class, education, and smoking

cessation: long-term follow-up of patients treated at a smoking cessation

unit. Nicotine & Tobacco Research, 8 (1), 29--36.

World Health Organization (2003). WHO Framework Convention on Tobacco

Control. [PDF]. Geneva, Switzerland.

Peralta, Genadrialine L. and Joseph Hunt (2003). A Primer on Health Impacts of

Development Programs. Asian Development Bank, 2003.

Levi, Dr. Fabio et al (1997). Lung Carcinoma Trends by Histologic Type in Vaud

and Neuchâtel, Switzerland 1974-1994. American Cancer Society, 1997.

Kuntsche, S. & Gmel, G. (2005). The smoking epidemic in Switzerland-an

empirical examination of the theory of diffusion of innovations. Sozial-und

Praventivmedizin, 50 (6), 344--354.

WHO (2011). WHO Report on the Global Tobacco Epidemic, 2011. [PDF]. World

Health Organization.


APPENDICES

Appendix I: ISP Work Journal

September 13th: ISP subject and justification due, selected smoking concerns in

Switzerland, specifically with youth and prevention programs

September 20th: Contemplate focusing ISP question on cultural interpretation of

the causes of smoking, leading to possible intervention programs. Begin

gathering research

September 23rd: Receive ISP initial question back from Nezha Drissi with

comments. Will go ahead with cultural analysis focus

September 25th: Work on Literature Review Essay, submit to Nezha and Dr.

Villadent

September 29th – October 11th: Field Study in Morocco

October 18th: Meeting with Nezha about project focus. Main focus should be on

the reasons why people start smoking, specifically youth. Got idea to go to

University of Lausanne to conduct research surveys of students

October 23rd: Talked to host dad Jean-Pierre Goetschmann about possible

survey at UNIL: gave me an alumni to contact, and also suggested I write

to the professors asking permission to go into their classes and hand out

surveys directly to students, or else have the professor email the survey

out to his students. Proceed to work on developing survey in both English

and French, to get most responses possible.

October 25th: First draft of survey

October 29th: Emailed Ana Caratsch and Nezha Drissi about the email survey

through students in Geneva and Vaud, and was informed that I must

complete the Internal Review Board (IRB) paperwork first. Filled out IRB.

Decided on research title: Smoking in Switzerland: Analysis of Youth

Perception of Cigarette Use

October 30th: Revise questionnaire and intro paragraph again, in English and

French. Revised and submitted IRB paperwork. Began to collect contact


information for universities to send survey to. Email Dr. Astrid

Stuckelberger as well to look for contacts.

October 31st: Collect contacts for University of Geneva. Asked Dr. Nidal Salim for

contact information, and began to look into the Unviersities of Neuchâtel

and Fribourg as well

November 1st: Think about doing paper surveys as well as online. Began to look

into professional interviews with tobacco industry leaders through Philip

Morris International and British American Tobacco, but these end up

fruitless

November 4th: Survey launched using a paid subscription to

FreeOnlineSurveys.com, emailed 56 people at the Universities of Geneva,

Lausanne, Fribourg, Neuchâtel, and the EPFL. More research collected.

November 6th: Received mail back from EPFL and UNIL that they would be

unable to participate. Forwarded survey on to Ana Caratsch’s son, Monica

Elton’s daughters, and some personal Swiss connections around Vaud.

November 7th: Contact private universities to get more responses, sent email to

Webster University Geneva.

November 4th – 20th: Survey open for responses

November 21st: Begin analyzing data and drawing conclusions

November 24th: Turned in presentation and handouts to Monica Elton and Nezha

Drissi via email

November 27th: ISP presentation

November 28th – 29th: Final editing, and submission of ISP to Monica Elton


Appendix II: Survey Questionnaire, English

The following is a survey on your personal opinion of cigarette smoking. This

survey should take less than ten minutes to complete. Please read the following

text in its entirety before beginning.

This survey is designed as a research project on smoking and its affects

specifically on young adults, as well as the reasons behind why people smoke.

This report is being created as an Independent Study Project by an America

student from Santa Clara University in California, in conjunction with the School

of International Training (SIT) through their Global Health and Development

study abroad program, based in Geneva and Nyon.

By completing this survey and submitting it, you give your consent to have your

responses used in a research analysis of the data provided. Your participation in

this study is completely optional. If at any time you feel that you do not wish to

continue with the survey, you may simply exit the window and your answers will

not be saved. Your responses are only recorded once the “Submit” button is

pressed at the end of the questionnaire. No personal data will be collected with

this survey that could identify you and your responses in any way.

Please do not participate in the survey if you are under 18. Thank you for your

participation.

1. What is your age? ______

2. What is your gender?

a) Male

b) Female

3. Are you a natural-born citizen of Switzerland?

a) Yes

b) No


4. Do you currently or have you ever smoked cigarettes?

a) Yes, daily

b) Yes, often (weekly)

c) Yes, rarely (monthly)

d) No, not currently

e) No, never

5. If you smoke, how old were you when you first smoked a cigarette (more than

a puff)? _______

6. Do any members of your immediate family currently smoke, or have they

during your lifetime?

a) Yes, currently

b) Yes, but not currently

c) No, never

7. Do any of your close friends smoke, or have they ever since you have known

them?

a) Yes, currently

b) Yes, but not currently

c) No, never

8. If you do smoke, have you ever considered quitting?

a) Yes, within the next month

b) Yes, within the next 6 months

c) Yes, sometime in the future but not now

d) No, I have not thought about quitting

e) I do not smoke

9. If you have ever smoked, what are the reasons that you chose to start? If you

do not smoke, what do you believe your peers’ reasons for starting are? Mark all

that apply.

-The taste

-Social connection or interaction

-To ease stress


-To have a good time

-Because it makes you look cool

-To seem older or more mature

-Other: ________________________________________________

10. What do you think when you see a peer smoking?

____________________________________________________________

11. Do you think that smoking is a serious health concern?

a) Yes, very serious

b) Yes, somewhat serious

c) Neither serious nor trivial

d) No, not very serious

e) No, not serious at all

12. On a scale from 1 to 5, 1 being the lowest and 5 being the highest, how

dangerous a behavior do you think smoking is?

a) 1

b) 2

c) 3

d) 4

e) 5

13. If you have any further comments, questions, or concerns, please list them

here:

Any further questions can be directed to Adam Whalen, [email protected].

Thank you for your participation.


Appendix III: Survey Questionnaire, French

Ce qui suit est une étude sur votre opinion du fumeur de cigarettes. Cette étude

devrait prendre moins de dix minutes. Lisez le texte complètement avant de

commencer à répondre, s’il vous plaît.

Cette étude est une partie d’un projet de recherche sur le tabagisme et ses effets

sur les jeunes. Aussi sur les raisons du pourquoi une personne fume. Ce projet

est un projet de recherche indépendant, effectué par un étudiant américain qui

vient de Santa Clara University en Californie, avec le School of International

Training (SIT) cours d’étude à l’étranger dans le domaine de la santé mondiale et

de développement basé à Genève et Nyon.

Si vous complétez et soumettez cette étude, vous donnez l’autorisation

d’utilisation de vos réponses dans une analyse de recherche. Votre participation

dans cette étude est complètement optionnelle. Si à n’importe quel moment vous

ne voulez pas continuer cette l’étude, vous pouvez quitter la fenêtre d’internet et

vos réponses ne seront pas sauvées. Vos réponses sont sauvées seulement

quand vous cliquez « Submit » à la fin de l’étude. Ce questionnaire n’associe pas

votre identité à vos réponses.

Pour participer à cette étude vous devez avoir dix-huit ans révolus.

Merci beaucoup pour votre participation.

1. Quel âge avez-vous?______

2. Quel est votre sexe?

a) Masculin

b) Féminin

3. Etes-vous né en Suisse?

a) Oui


b) Non

4. Fumez-vous des cigarettes actuellement où avez-vous toujours fumé?

a) Oui, tous les jours

b) Oui, souvent (chaque semaine)

c) Oui, rarement (chaque mois)

d) Non, pas actuellement

e) Non, jamais

5. Si vous fumez, à quel âge fumez-vous une cigarette pour la première fois (plus

que une bouffée)? ________

6. Il y a t’il quelqu’un de votre famille immédiate qui fume, actuellement ou tout

les temps?

a) Oui, actuellement

b) Oui, mais pas actuellement

c) Non, jamais

7. Il y a t’il quelqu’un parmi vos amis proches qui fume, actuellement ou tout le

temps?

a) Oui, actuellement

b) Oui, mais pas actuellement

c) Non, jamais

8. Si vous fumez, avez-vous pensé arrêter de fumer?

a) Oui, dans le mois prochain

b) Oui, dans le 6 mois prochains

c) Oui, dans le futur mais pas maintenant

d) No, je ne pense pas arrêter de fumer

e) Je ne fume pas

9. Si vous avez déjà fumé, quelles sont les raisons pour lesquelles vous avez

commencé à fumer ? Si vous ne fumez pas, selon vous quelles sont les raisons

pour lesquels vos amis fument-ils ? Sélectionner la phrase qui convient.

--Le goût

--Lien ou interaction sociale

--Pour soulager le stress


--Pour s’amuser

--Parce que cela vous donne l’air cool

--Pour avez l’air plus âgé ou adulte

--Autres :

_______________________________________________________

10. Que pensez-vous quand vous voyez quelqu’un de jeune fumer?

11. Pensez-vous que la fumée est une préoccupation grave de la santé?

a) Oui, très grave

b) Oui, assez grave

c) Ni grave ni insignifiant

d) Non, pas très grave

e) Non, pas grave du tout

12. Classez de 1 à 5, si 1 est le plus bas et 5 et le plus haut, comment

classeriez-vous le risque de la santé du fumeur?

a) 1

b) 2

c) 3

d) 4

e) 5

13. Si vous avez d’autres questions, remarques, ou préoccupations, s’il vous

plaît voulez-vous les énumérer ici:

Si vous avez d’autres questions, pouvez-vous les envoyer à Adam Whalen,

[email protected]. Merci beaucoup pour votre participation.


ACKNOWLEDGEMENTS

I would like to thank the following people for their support in my research. Without

them, this project could not have been realized and completed fully. Jean-Pierre

and Marianne Goetschmann, Ana Caratsch, Nezha Drissi, Christian Villadent,

Derick André, Leandra Kall, Dr. Nidal Salim, Aurelie Zioerj, and Monica Elton.

Thank you all for your invaluable help!

Documents

Adam Whalen ISP