Swiss adolescents' and adults' perceptions of cannabis use: a qualitative study

Abstract

Few studies have attempted to investigate the nature of adolescents' and adults' conceptions and perceptions of cannabis use. Our objectives were to explore adolescent and adult perception of use and misuse of cannabis, and their opinions and beliefs about the current legal context and preventive strategies. We used focus group discussions with four categories of stakeholders: younger (12–15 year old) adolescents, older (16–19 year old) adolescents, parents of teenagers and professionals working with young people. In some areas (legal framework, role of the media, importance of early preventive interventions), we found consensual attitudes and beliefs across the four groups of participants. In all four groups, participants did not have any consensual vision of the risks of cannabis use or the definition of misuse. In the area of the prevention of cannabis use/misuse, while parents focused on the potential role of professionals and the media, thus minimizing their own educational and preventive role, professionals stressed the importance of parental control and education. Within the Swiss context, we conclude there exists an urgent need for information and clarification of the issues linked with cannabis use and misuse directed at parents and professionals.

Introduction

In Switzerland, as in many other European countries, substance use by teenagers is growing and has become a major public health issue (Hibell et al., 1997; European Monitoring Centre for Drugs and Drug Addiction, 2002; Narring et al., 2003; Schmid, 2003; Currie et al., 2004). While alcohol remains the legal psychoactive substance predominantly used by adolescents, cannabis is the illegal one which is the most often consumed. In Switzerland, according to the ‘Health Behavior of School Children’ surveys conducted among a national sample of 15-year-old teenagers, the lifetime use (i.e. use of cannabis at least once in one's life) of cannabis has increased practically four times from 1986 to 2002, and is currently 49.9% among boys and 39.1% among girls (Schmid, 2003). Moreover, the age at which cannabis is consumed for the first time is declining, having fallen from 16.5 years in 1992 to 15.8 years in 1999 (Müller and Gmel, 2002; Kuntsche, 2004). As a result of this situation, policies regarding cannabis use constitute a hotly debated issue in Switzerland (Strang and Hall, 2000; Kapp, 2003) as well as in other countries (MacCoun and Reuter, 2001; Wodak and Drummond, 2002). Currently, the law in Switzerland bans the use of cannabis, a legal context which was reinforced in June 2004 by a decision of the Parliament not to decriminalize the use of cannabis by adults. However, the application of the law is uneven from one region (canton) to another. Some parts of the country are de facto fairly liberal, while others apply the law strictly. As recently stated (Kapp, 2003), this discussion is often obscured by irrational considerations and it most often focuses too narrowly on purely political issues, while it should take into account the points of view of the population in general (Kohn and Piette, 1997; Longchamp et al., 1998; Wibberley and Price, 1998; Boys et al., 2001; Institut Suisse de Prévention de l'Alcoolisme et Autres Toxicomanies, 2001, 2002).

Recently, an increasing number of studies have attempted to assess the nature of individual and social conceptions and perceptions of substance use, focusing for instance on the effect of the social network and environment as well as the role of adolescents' opinions concerning such behavior (Allbutt et al., 1995; Kohn and Piette, 1997; Wibberley and Price, 1998; Wyvill and Ives, 2000; Boys et al., 2001; Calafat, 2001; Le Garrec, 2002; Highet, 2003; Amos et al., 2004). Most of this research is of a qualitative nature, using focus group or interview approaches, since a detailed exploration of individuals' perceptions is hard to conduct through self-administered questionnaires (Highet, 2004). However, these publications tend to focus exclusively on adolescent perceptions, thus underestimating the importance of parents' and other adults' opinions; we are currently unaware of qualitative research pertaining to cannabis use by young people which has also involved adults. The present study aims to shed light on the meaning of use and misuse of cannabis in the present Swiss context, as well as the opinions and beliefs about legal and preventive issues, both from the perspective of young and older adolescents, and from that of adults, either parents or professionals caring for young people. Several hypotheses led to the present study: a first hypothesis was that there would be differences in the way adolescents and adults characterize cannabis, as well as the way they define use versus misuse. We have purposely focused on the concept of misuse which can be understood as problematic use or potentially harmful use, not necessarily fulfilling the DSM IV criteria for abuse and dependence. We also hypothesized that adults would be far stricter than teenagers in the way they look at the enforcement of the law and that adolescents themselves would be more in favor of a decriminalization of cannabis use.

Methods

The study was carried out in the state (canton) of Vaud, using focus group techniques (Morgan, 1993; Krueger, 1994; Fountain, 2000) applied to the following four target audiences: younger adolescents, older adolescents, parents and professionals working with teenagers. To allow for a large representation of various socioeconomic backgrounds, the adolescents were recruited, irrespective of their status as cannabis consumers (which was originally unknown to the researchers), via healthcare services as well as by school nurses and staff of shelter homes. Parents were recruited via parents' associations, during conferences for parents and through word of mouth. The professionals (school nurses, pediatricians and general practitioners, social workers, and teachers) came from the youth protection service, family planning clinics, two foster homes, two secondary schools and two medical private practices, again to display a wide array of opinions and beliefs. The participants were, respectively, 13 young adolescents aged 13–15 (eight girls and five boys) and 19 older adolescents aged 16–19 (nine girls and 10 boys). Eight adults (five mothers and three fathers, unrelated to each other) made up the parents' group. They all were parents of teenagers, but unrelated to the adolescent participants. Thirteen professionals (seven females and six males) made up the other adult group. The uneven number of members of the four groups is linked to several elements: (1) the researchers over-recruited potential participants, especially among older teenagers, (2) there were more last minute drop outs among younger adolescents and parents, and (3) there were a surprisingly high number of older teenagers who did attend, three of them coming in with a friend.

All the participants received oral and written information concerning the study, the research objectives, and the way the information would be used and treated. Written consent was obtained from all participants and from the parents of those under 15 years of age. The participants were invited to respect the confidentiality of the discussion and asked not to disclose its content once the session was over. Adolescents or parents who might mention personal difficulties could be referred to a healthcare service. All the participants have received a summary of the main results. This study has been reviewed by the Ethical Commission of the Medical Faculty of the University of Lausanne.

Four different sessions were run, one for each target group, with a duration of about 90 min. The sessions took place during May 2003. A topic guide including five main questions structured the discussion of each session:

1. How is cannabis defined and perceived?

2. Why do adolescents begin to use cannabis and why do some of them use it on a regular basis?

3. What is considered as cannabis misuse and what are the risks linked with misuse?

4. What are the points of view regarding the present legal context and how should it evolve?

5. How can prevention be set up and improved?

During the discussions, some other issues inevitably emerged. The young people wondered, for example, why some adolescents do not use any cannabis, and what relationship exists between tobacco and cannabis use. Parents and professionals debated the role of social context in substance use. However, to keep the study and discussion within its time frame, the discussion was purposely focused on the five questions mentioned above. The discussions were conducted in French and they were quite lively, with some people participating more often than others. The size of the group did not appear to impact on the content and quality of the debate very much. The flow of the discussion was smooth, with many spontaneous interactions between the participants. Younger adolescents tended to be more hesitant to speak and, therefore, the moderator intervened more often in this group than in the three other groups.

All the transcripts were tape-recorded and then typed. Given the exploratory nature of the study, no formal computerized analysis of the content was run. According to methodology used in qualitative research (Morgan, 1993; Krueger, 1994; Le Garrec, 2002), the transcripts were read several times by all authors to progressively bring out the main ideas, beliefs and opinions expressed in the four targeted groups of individuals. Regular discussions were then held to achieve a consensus on the most prevalent attitudes and beliefs expressed in each group. Various formulations were compared and contrasted to achieve a global view of the range of opinions held by the subjects. The quotations have been translated into English as faithfully as possible with the mention of the age and sex of their author.

Results

Cannabis: how is the substance defined and perceived?

Most younger participants defined cannabis as a drug, a substance with psychoactive properties which can potentially induce dependence. They insisted on the potentially harmful effects of cannabis on both physical and mental health:

It's a drug because its has side-effects; I know of a friend who looked very odd because he had smoked too much cannabis…it diminishes your driving ability, you can't drive anymore. [Girl, 14]

Most older adolescents considered cannabis as similar to tobacco and alcohol, these last two substances being, according to some of the participants, even more dangerous than cannabis since one gets addicted to them faster:

In fact, alcohol and cigarettes are far more dangerous, you see, cigarettes are a drug, you get hooked quite easily. [Boy, 18]

For several teenagers, cannabis should not even be considered as a drug, in contrast to substances such as hallucinogens, heroine or cocaine, and as such it should be treated in a way similar to alcohol. While younger adolescents focused their definition on the harmfulness of cannabis, older adolescents tended to include in their definition the way the individual uses it and the extent to which it disturbs one's mental functioning:

It's a substance you may get dependent on, but if you take it once or twice it's not a drug at all. [Girl, 19]

The responses from adults (parents and professionals) were far from uniform and what emerged was the fact that they felt a bit lost when having to characterize cannabis: several participants tended not to categories it as a drug as long as it is taken casually. Several parents and professionals also mentioned that they did not really know to what extent cannabis is a potentially dangerous substance, both in the short or long term:

You don't know if it's a drug, maybe it's like drinking a glass of wine. [Mother]

It's clear that I personally still don't know if it is dangerous or not. [General practitioner]

Why do adolescents begin to use cannabis and why do some of them use it on a regular basis?

Younger adolescents all stressed the impact of group pressure and of individual peer pressure on engaging in cannabis use. Smoking marijuana can increase a sense of belonging, of being like everyone else and is consequently quite attractive. Also, smoking cigarettes is no longer a prerequisite for marijuana use, since young people tend to start with it before they begin to smoke tobacco. Some participants suggested that if one wants to be respected by his friends, one has to use cannabis. Many also emphasized the role of curiosity and sensation seeking:

I don't know of many adolescents who have liked cannabis from the very beginning; you know they just begin to show up…maybe it's reassuring, you are part of the group, you are old enough. [Boy, 15]

Older adolescents expressed a different view: although they insisted on the importance of peer pressure, they also stressed the importance of physical pleasure and of the availability of cannabis which, they think, can be found nowadays nearly everywhere in towns and larger cities of Switzerland:

It's a new sensation, you feel something else. [Boy, 17]

To them, cannabis use is part of our consumer society: you get your cellular phone, your moped, you have to enjoy life. It is a consumption like many others. It was even considered as a deviant posture nowadays to totally abstain from consuming cannabis. They also mentioned that most parents would not object to the casual use of cannabis:

My parents have just asked me not to smoke at home or in my relatives' home, otherwise, they don't care. [Girl 16]

This last opinion was echoed by most of the parents, who declared they were not against experimenting with cannabis. Most of them didn't really object to their children consuming cannabis from time to time. To them, it was nevertheless important that young people experimenting with cannabis should be in a good state of mind, in self-control and not alone. Several professionals had the same point of view:

Don't our children have the right to smoke cannabis just for fun? OK you don't have to encourage them but from time to time, you know, there is nothing to worry about. [Father]

I have colleagues who smoke themselves so they think it's OK for their kids to smoke too. I had a discussion with my colleagues in my school about cannabis…we have not been able to achieve any consensus in this area. [School nurse]

Interestingly, most adolescents and professionals agreed on the fact that rebellion was no longer a ground for beginning to smoke cannabis, because it had become so common to at least try it. Some parents, however, still believed that transgression does play a role:

Alcohol in our society is permitted while for cannabis, you know, there is a kind of transgression. [Mother]

Tobacco is legal while cannabis isn't; it's a way to defy the taboo. [Mother]

Yes, a kind of provocation. [Father]

Another striking aspect of the parents', particularly the mothers', discourse was an apparent feeling of powerlessness linked to the idea that once their adolescents began to go out, they themselves had just lost control over the situation:

You can do want you want, once they start going out, they don't belong to us any more…it makes me fearful. [Mother];

You cannot stay with your children all day long; managing the outside is a tough task. [Mother]

What is considered as cannabis misuse and what are the risks linked with misuse?

For younger teenagers, misuse was often defined in a purely quantitative way, when one consumes ‘too much’ cannabis. However, the quantification of ‘too much’ varied among participants (from once a month to two or three times a day). Some older adolescents as well as some parents similarly mentioned frequency and doses to define what they meant by misuse:

Yeah, you smoke more and more, everyday. [Boy 16]

If you smoke everyday. [Father]

If you smoke constantly, regularly. [Mother]

You get used to it, you have to increase the doses. [Mother]

Several older adolescents included in their definition the relationship that the individual establishes with the substance, i.e. to what extent one is hooked or needs to consume cannabis on a regular basis in order to keep control over one's stress or bad mood:

Maybe if they smoke with their friends it's OK, but if they start to smoke alone, well they are dependent. [Girl 18]

They want to forget about their problems and leave them behind, its no longer for fun. [Boy, 18]

Some of my friends, they cannot go to sleep without having smoked their joint. [Boy 17]

Although some professionals defined misuse as consumption more than once a day, or considered it as potentially harmful if the person was under 18 years of age, the majority felt that consumption was problematic as soon as it led to psychosocial consequences such as learning problems or deviancy, insisting on the fact that some adolescents are more vulnerable than others:

Some of them take cannabis as a medication, which in fact underlies psychological or psychiatric problems. [Social worker]

Smoking cannabis is a way to escape a problematic situation…you have to look beyond the use, the substance, and look for the teenager's distress. [Nurse]

I know of teenagers who have taken cannabis daily and succeeded in their exams…but if you have psychiatric problems, cannabis brings a lot of problems. [Teacher]

The issue of legislation and enforcement of the law

The majority of young adolescents were against decriminalization of cannabis, thinking that it would increase accessibility, encourage older adolescents to pass on cannabis to younger ones or even that it would raise the risk of escalation into hard drug use:

I am totally opposed to legalization; decriminalization means that one accepts cannabis use as normal. [Boy 15]

If you have the right to do it, every child will think that it's also OK for him. [Girls 14]

However, young adolescents recognized at the same time that access to cannabis for individuals less than 18 years old was easy and that society was unable to enforce the law. They stressed the fact that adults in general did not react when young people were seen consuming cannabis in public places. Most older adolescents were in favor of decriminalization, which according to them might reduce the number of illicit dealers since there would be licensed coffee shops. In fact, some of them were quite sure that decriminalization had already been endorsed by the government, and that the selling and use of cannabis was totally legal in Switzerland:

Good that there won't be too many dealers, instead coffees [coffee shops]; at least one knows what one buys. [Boy, 18]

As the law is not applied currently anyway, it is pure nonsense to be against decriminalization. [Girls, 16]

It's crazy, some teachers have young people smoking pot just in front of them and they don't react. [Boy, 16]

Most adults declared that cannabis use should be legally permitted for adults (above 18 years of age) and that the law should be applied:

It is not so much the law itself, it's the way you apply it. [Teacher]

The law is one thing, but what is really important is the way the school and the adults express themselves regarding this topic. [Social worker]

Thus, nearly all professionals and many parents agreed on the fact that social norms regarding the use of cannabis had changed a lot over the last two decades, and that, irrespective of the law, adults and society should transmit clearer messages regarding the potentially harmful effects of cannabis use/misuse, especially on minors.

Prevention

Interestingly, in all four groups, although there was a lot of discussion around the issue of prevention, there were no formal exchanges around the issue of what to prevent exactly: cannabis use, cannabis misuse or, more broadly, substance misuse. Most adults, and even the adolescents themselves, reported being confused by the messages conveyed in the media. Some papers or broadcasts seemed to be stressing the risks linked with cannabis use, while others seemed to be minimizing the problem. The two adolescent groups mainly focused on the role of the school, while the two adult groups emphasized the role of parents and of the media. For both younger and older adolescents, preventive activities in the school should start very early, at 11 or 12 years of age, given the decreasing age of access to legal and illegal psychoactive substances. Most of the teenage participants thought that focusing on the effects of the substance was useless and that prevention should target the issue of misuse and dependence in general. These sessions (if possible, group discussions) should be led, according to them, by specially trained people and should not be the responsibility of the normal teaching staff. Some young adolescents thought that prevention should also be promoted outside school, in youth clubs and by using media (television, magazines).

We should more often have the kind of discussion we had tonight. [Girl, 19 years];

You should begin earlier with everything you see, cigarettes, alcohol, then maybe cannabis by around 12 years. [Boy, 14]

The discussion among professionals focused on the attitudes of parents who should, in their opinion, put more restrictions and limits on young people until 18 years of age:

The role of the parents after all is still to say no, or to say no until you have attained legal age. [Social worker]

When I see all these younger teenagers who hang around in the streets, who smoke their joints, these children have no limits, no time to come back home, how can we help these parents to educate their children? [Family planning counselor]

Parents focused much more on the statements conveyed by the media and asked for clearer, less ambiguous messages, both from the media and from health professionals. However, there was no real consensus among parents concerning what form the messages should take. Some advocated the use of scare tactics, while others advocated a focus on the advantages linked to abstention:

It's true that the media should deliver clearer messages. [Mother]

They need to face reality, concrete messages such as danger, do not, etc. [Mother]

It's not that easy, you don't die from cannabis, maybe we should focus on other strategies, what they gain if they don't consume. [Mother]

Discussion

Our main hypothesis was that there would be differences in the way adolescents, on the one hand, and parents or professionals, on the other, would characterize cannabis use and misuse, as well as the way they would propose to address this issue, both in terms of policymaking and preventive interventions. Such a clear-cut contrast did not emerge—the situation being far more complex. There were as many differences among the adults or among the adolescents themselves as between adults and adolescents. Moreover, there were no real gender differences, and the contrasting views and opinions were uniformly spread both among male and female participants. All four groups agreed that even though a political decision regarding decriminalization was pending (it has since then been rejected), cannabis use and sale was de facto tolerated in several parts of the country. Also, there was a consensus, both among the majority of teenagers and adults, that access to cannabis by young adolescents (i.e. 14 years) should be forbidden and actively enforced, although many adolescents recognized that this was not currently the case. Along the same line, younger and older adolescents asked for preventive interventions which should begin earlier, around 11–12 years of age.

In many areas, the picture from the four groups displayed diversity. One area was the issue of the definition of misuse: while younger adolescents and several parents tended to define misuse in terms of frequency and quantity consumed, older adolescents as well as professionals focused more on the issue of the user's vulnerability, the short- and long-term risks of misuse being connected, according to them, with psychological, social or environmental problems. The perceived type of risk of misuse also differed: younger adolescents, among whom none disclosed any personal experience with use of cannabis, stressed the potential physical danger of the substance, asking for more information from specialists and for more stringent rules within the school setting. Among older adolescents, there were abstinent, experimental and regular users of cannabis: however, the type of consumption did not seem to have any impact on the opinions expressed. Most older adolescents seemed tolerant towards cannabis use and several members of the group would consider daily use still as recreational, provided the user did not experience any social or professional side-effects and was not underage. These opinions were in fact not that different from the ones expressed in other similar qualitative studies (Boys et al., 2001; Le Garrec, 2002; Amos et al., 2004; Highet, 2004).

One other topic touched on the role of the law and, more broadly, of preventive measures. It is not so much the role of the law per se which was discussed, as the fact that prevention should focus on how it was interpreted and applied, and the climate of the public discourse concerning cannabis use, more generally. In this respect, there was some contradiction between the parents and the professionals. One salient aspect of the parents' discussion was their apparent tolerance for their own children experiencing cannabis, and their expectation for strong preventive, deterrent messages from the media and experts. This apparent delegation may be linked with the fact that, as two mothers said, some parents develop a sense of helplessness once their adolescent children begin to go out. It seemed as if they felt they had to pass on their educational responsibility to other adults once their children had reached a certain point in adolescence. The professionals—some of them faced with severe situations in their everyday work—expressed a contrasting opinion, many of them underlining the fact that parents should be able to say ‘no’ to their children, even during adolescence. It is thus intriguing that each group of adults asked for the intervention of other members of society. We have been unable to find similar qualitative studies exploring the beliefs and attitudes of adults towards cannabis use in comparison with those of young people.

There are several limitations to this exploratory study. First, as is the case for all qualitative studies, although we have tried to reach a heterogeneous sample of young people and adults, we cannot assert that it was representative of French-speaking Switzerland. Beliefs and attitudes towards psychoactive substances are heavily rooted in subcultures (Highet, 2003), and we cannot dismiss the fact that parents from minority groups living in the same area may have expressed themselves in a different way. Also, some of the opinions expressed by younger adolescents may be partly shaped by a social desirability phenomenon. The particular legal and political context in Switzerland limits the generalization of our results to other countries; however, given the current spread of the consumption of cannabis and other psychoactive substances in most European countries (Calafat, 2001; Hibell et al., 1997; Chabrol et al., 2002; European Monitoring Centre for Drugs and Drug Addiction, 2002; Currie et al., 2004), we think that these results may still partly apply to other Western countries.

What are the implications of these results ? First, within the Swiss context, given the somehow blurred vision which many adults had of the physiological, medical and psychological properties of cannabis, there certainly exists an urgent need for thorough information regarding the definition and risks of misuse, and its application in different ages and contexts. It has been recently suggested that the content of the law itself does not play a crucial role in the development of substance use (Reuband, 2001; Reinarman et al., 2004); it may well be that it is the type and content of messages which are delivered within society in general, by parents, teachers and journalists, which shape the adolescent's behavior in this area, as well as the way the law is applied. For instance, in some Scandinavian countries (Sweden, Finland) where public discourse clearly and consistently states that consuming cannabis and illegal drugs is bad, the proportion of young people engaging in such consumption is lower than in countries such as Switzerland (Currie et al., 2004) where such consumption is probably trivialized. Parents should be made aware of the importance of delivering consistent messages regarding this topic both before and during adolescence, and they should not rely only on professionals working in the area of education, social and health services.

Finally, both the existing literature (Patton et al., 2002; Solowij and Grenyer, 2002; von Sydow et al., 2002) and the opinions expressed by the adolescents themselves suggests that prevention should aim at postponing the age at which young people first experience cannabis, if they are inevitably going to do so. There are indications that, besides the main messages delivered by adults involved in healthcare, specific interventions both within the family and in the school setting (Botvin, 2000; Tobler, 2000; Kumpfer et al., 2003) are effective. Swiss professionals should be better informed and trained to set up such interventions. Both younger and older adolescents ask for such early interventions, if possible before the age of 13–14 years.

We would like to thank all the participants of this study, the recruiters, the school administrations and medical services as well as the secretaries of IUMSP and UMSA for their assistance in the organization of the focus group sessions.

References

Author notes

1Research Group on Adolescent Health and 2Unit for the Evaluation of Preventive Programs, University Institute for Social and Preventive Medicine, CHUV, 1011 Lausanne, Switzerland