Original article

Why did Swiss citizens refuse a comprehensive second-hand smoke ban?

DOI: https://doi.org/10.4414/smw.2014.13983
Publication Date: 24.07.2014
Swiss Med Wkly. 2014;144:w13983

André-Dante Durhama, Pascal Diethelmb, Jacques Cornuza

a Department of Ambulatory Care and Community Medicine, Lausanne University Hospital, Lausanne, Switzerland
b OxyRomandie, Geneva, Switzerland

Summary

The ill effects of second-hand smoke are now well documented. To protect the population from exposure to tobacco smoke, comprehensive smoking bans are necessary as expressed in the WHO Framework Convention on Tobacco Control and its guidelines. Switzerland has only a partial smoking ban full of exceptions which has been in effect since 2010, which reproduces the so-called Spanish model. In September 2012, the Swiss citizens refused a proposal for a more comprehensive ban. This case study examines the reasons behind this rejection and draws some lessons that can be learnt from it.

Key words: tobacco smoke pollution; health policy; public policy; public opinion; Switzerland

Introduction

It is now well documented that exposure to second-hand smoke causes cancer, heart disease, lung disease, and childhood illness. Second-hand smoke is estimated to be responsible for over 600,000 deaths worldwide each year [1]. Despite this knowledge, many countries do not have comprehensive smoking bans to limit second-hand smoke exposure and often neglect workers in hospitality venues entirely despite their high exposure rates.

Swiss citizens voted on a constitutional initiative to protect against second-hand smoke by banning smoke from enclosed workspaces or areas accessible to the public in September 2012. A total of 42.3% of the eligible voters participated in this vote; 66% of the voters rejected the initiative.

The aim of this article is to look at the reasons for this rejection, providing a case study of a failed public health initiative.

Background

Exposure to second-hand smoke is responsible for respiratory symptoms, lung cancer, myocardial infarction and stroke, among other diseases [2]. As the health risks associated with second-hand smoke became more apparent, smoke-free regulations in workplaces as well as indoor public places, including hospitality venues, were progressively introduced in a number of jurisdictions at a local or national level. On 1 May 2010 the Swiss Parliament passed a nationwide smoking ban although not a comprehensive one. This partial smoking ban follows the so-called Spanish model [3]. While it covers most work spaces and public indoor areas, it includes notable exceptions: smoking establishments are authorised if they are smaller than 80 square meters; dedicated smoking rooms with full service are allowed in larger establishments, employees having to work in a smoking environment are merely required to have a statement in their employment contract saying that they agree to be exposed to tobacco smoke. The Swiss legislators have resolved the issue of occupational safety and health with respect to exposure to tobacco smoke, a well-known carcinogenic agent, in a rather peculiar way: by discharging the employers from this responsibility and transferring it to the employees. The workforce is split into two categories, one which enjoys full protection from second-hand smoke (i.e., those working in smoke-free establishments) while the other must suffer its consequences and is required to assume responsibility for the lack of protection.

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Figure 1
Map of the different cantonal legislations regarding exposure to second-hand tobacco smoke.
AG: Aargau; AI: Appenzell Innerrhoden; AR: Appenzell Ausserrhoden; BE: Bern; BL: Basel-Landschaft; BS: Basel-Stadt; FR: Fribourg; GE: Geneva; GL: Glarus; GR: Graubünden; JU: Jura; LU: Lucerne; NE: Neuchâtel; NW: Nidwalden; OW: Obwalden; SG: St. Gallen; SH: Schaffhausen; SO: Solothurn; SZ: Schwyz; TG: Thurgau; TI: Ticino; UR: Uri; VD: Vaud; VS: Valais; ZG: Zug; ZH: Zurich. (Figure courtesy of the Swiss Lung Association)
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Figure 2
Main poster used by opponents to the initiative (French version).

Fortunately, Swiss direct democracy offers political tools to improve its policies. Namely, cantons (political and administrative subdivisions of Switzerland) can adopt stricter laws. When the national smoking ban came into force, 15 out of the 26 cantons already had stricter laws, and 8 of them had nearly comprehensive smoking bans with as sole exception the possibility for public establishments to have a dedicated smoking room of limited size and without service (fig. 1). Another tool at the disposal of the population is the ballot initiative which allows citizens to demand that a modification of the Swiss Constitution be put to a popular vote.

In May 2009, a large alliance comprising more than 40 organisations, under the leadership of the Swiss Pulmonary League, launched an initiative proposing a simple and nearly comprehensive indoor smoking ban in all work places and indoor public places. The vote was preceded by a campaign for the initiative mostly organised by the Swiss Pulmonary League and a campaign against it by an ad-hoc committee of opponents. The campaign pro and con started approximately in the middle of August and intensified as time got closer to the closing day of the ballot. The Swiss population voted on the initiative on 23 September 2012.

Arguments supporting the initiative

The health impact of second-hand smoke is well documented. The results from the Swiss SAPALDIA study clearly showed the negative health effects of second-hand smoke exposure in the work environment [4]. The impact of smoking bans in cantons where stricter tobacco bans are in place show the health benefits of such measures. The canton of Graubünden reported a more than 20% reduction in hospital admissions due to myocardial infarction after a ban [5, 6] and similar results were reported in the canton of Ticino [7]. A study from the canton of Vaud reported an improvement in lung function, physical well-being and respiratory symptoms among hospitality workers after a similar ban [8]. A study in the canton of Geneva described a 19% reduction in hospitalisations for chronic obstructive pulmonary disease and pneumonia after its comprehensive ban [9].

The current federal smoking ban is lax but allows cantons to implement stricter regulations. At the time of the vote, 15 of the 26 cantons already had stricter regulations in place, 8 of which are very similar to the demands of the initiative. This “patchwork” situation is confusing to the Swiss and even more so for tourists. Workers in various cantons do not have the same rights as some are not protected from second-hand smoke and must even give written consent to work in a smoking environment. Other environmental pollutants as well as radiation are regulated at the federal level with the same maximal tolerated doses throughout the country and no one would call this into question. The proponents of the initiative invoked the fundamental principle of equity, saying that the right to health should be the same for all people in Switzerland, independently of the canton in which they live and work and of their occupation: Their motto was “Already eight cantons are smoke-free. Let’s have an equitable law for all.” Proponents also put forward the simplification that would result from having a single law for the whole country, which was clear and straightforward to implement, thus reducing the bureaucratic burden.

The negative economical aspect of second-hand smoke bans on the hospitality business is often referred to by tobacco proponents but a large body of evidence shows that such bans have no impact or even a positive impact on the economy [10], and this argument was even verified locally after a ban in the Swiss canton of Ticino [11] which was published a few weeks prior to the ballot and thus received some attention from the press as well. Comprehensive country-wide smoking bans do not affect the economy but patchy ones where neighbouring regions allow smoking may. Moreover, the health costs related to second-hand smoke in a small country such as Switzerland, with a population of 8 million, have been estimated at 330 million CHF a year [12].

Arguments against the ban

A national campaign to persuade Swiss citizens to reject the initiative was organised by a large group of political representatives mostly from centre and right wing parties and backed by private funds; they called their group the “No to an absolute smoking ban” Committee (fig. 2). Their campaign used the following arguments (table 1):

Uselessness of the initiative: The current federal law addressing second-hand smoke had been recently adopted, in 2010, i.e., two years earlier. The opponents claimed that the current law was the result of a good compromise from all parties and that the new initiative did not introduce any substantial improvements. They specifically asserted that the population was already well protected from second-hand smoke. They stated that many businesses had made important investments after the entry into force of the current law, for example to equip their establishment with a dedicated smoking room and said that a new change would compromise legal security. A ban was also claimed as useless since the numbers of smokers was steadily decreasing.

Loss of local autonomy: The opponents of the ban argued that the initiative forced strict rules on all of the cantons in a field where the cantons are supposed to be free to adapt their own legislation according to the principles of federalism. They argue that many cantons had already adopted stricter rules regarding passive smoking.

Detrimental to the economy: The opponents argued that the initiative would have a negative impact on the hospitality industry. According to them, 30% of the members of GastroSuisse (the national federation of local hotel and restaurant associations) saw a significant drop in business after the implementation of the current law. Moreover, they stated that many businesses already underwent costly renovations in order to comply with the current law and that these investments would be lost if the law were to change again as stipulated in the initiative. The argument that hotels would not be able to have smoking rooms was promoted as well. They also alerted the public about the detrimental impact on other sectors of the economy, notably suppliers, advertisement and communication companies. Finally they claimed that the initiative would lead to job losses and a drop in the quality of services.

Loss of individual liberties: The opponents claimed that the initiative was a loss of freedom and that citizens were treated like children. Furthermore, they claimed that if the initiative was accepted, the state would soon regulate every area of our privacy. Finally, they claimed that the real intentions of the instigators of the initiative were for a society where smoking is completely prohibited. They claimed that the initiative was “extremist” and dishonest as they believed the supporters had a hidden prohibitionist agenda and were using a “salami tactic” of always making the restrictions more severe. They referred to another initiative which was still at the stage of collecting signatures, but was stricter than the initiative at vote, as it would even extend the ban to exclude dedicated smoking rooms without service and would ban smoking outdoors in certain settings, despite it coming from an individual uninvolved with the present campaign. This other initiative was labelled completely extremist, while in fact it proposed nothing other than a strict implementation of the best practices indicated in the WHO Framework Convention on Tobacco Control (FCTC) guidelines on the application of Article 8.

Table 1: Arguments against the ban by the opposition committee and counter arguments.
Uselessness of the initiativeSecond-hand smoke is harmful. Many workers are still exposed due to the exceptions from the present ban.
Loss of local autonomyHealth hazards and atmospheric pollutants should not be regulated at a local level. Patchy regulations are confusing.
Harmful to the economySeveral studies show no change or improvements in the economy after comprehensive smoke bans.
Loss of individual liberties“One’s personal freedom ends where another’s begins”. Hospitality workers must sign a clause that they accept the ill effects of second-hand smoke on their work contracts.
Table 2: Reasons for the refusal of the comprehensive smoking ban by the Swiss population.
Unbalanced fightHealth specialists vs committee backed by undisclosed private donations.
Different campaign messagesProtection against second-hand smoke vs the very existence of smokers.
FederalismUniform countrywide policy vs maintenance of local authority.
Lack of support by the government and parliamentOfficial government booklet recommending to vote against the initiative. A majority of political parties against the ban.
Lack of support from the pressTobacco advertisements remain one of the most important sources of revenue for the written press.
Difficulties in applying initiativesRecent accepted initiatives prove to be a headache to implement. Uncertainties in present initiative.
Shortage of time for campaigningJust over a month given to campaign.
Recent federal lawCurrent law dates from May 2010 and introduces many improvements. A new law would require many new adaptations.
Poor comprehension of the health issues by the populationMost people believe that air pollution is more harmful than second-hand smoke and did not believe the initiative to be useful.
Framing of the issue at stake exposed to loss aversionThe issue at stake was framed positively by the proponents of the initiative, leaving the negative framing entirely to opponents, who took advantage of loss aversion, Furthermore, the positive framing was weakened by slogans that were too general and with poor graphic design of the ads.

Why did Swiss citizens refuse a comprehensive smoking ban?

With two thirds of the voters rejecting the initiative, which furthermore was opposed by all cantons except one, including those where a similar ban was already in place due to successful cantonal initiatives, the proponents of the initiative were justifiably very disappointed by the result of the ballot box. Although they knew that there was no certainty that the initiative would be adopted by Swiss citizens, they did not expect such an overwhelming defeat. Was this result predictable and have the supporters of the initiative been victims of some kind of delusion? Or did something happen that radically changed the outcome in the last few weeks before the vote? Did the proponents of the initiative make some strategic or tactical mistakes in their campaign that offered crucial opportunities to their opponents to defeat them? Most likely, the true answer is a qualified yes to each of these questions. It is thus important to consider the plausible reasons for this failed public health initiative, in order to draw the necessary lessons and transform this setback into an experience which will help develop more effective public health policies in the future (table 2).

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Figure 3
Result of the vote as a function of the current level of protection against exposure to second-hand tobacco smoke (percent of voters who have accepted the initiative).
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Figure 4
Sample advert in support of the initiative.

Unbalanced fight between supporters and opponents of the ban

The initiative for the ban of second-hand smoke was initiated by the Swiss Lung Association and placed under the steering of a group of health specialists. It was backed by the Swiss doctors as well as other healthcare professionals associations, many health promotion organisations, youth organisations, consumer and workers’ defence organisations. This alliance raised 1.5 million CHF for their campaign. The opponents consisted of an ad-hoc committee of politicians and were backed by private donations; they refused to disclose their funding including the fact as to whether they received contributions from the tobacco industry. Switzerland is home to three major tobacco firms, British American Tobacco, Philip Morris International and JT International, having headquarters, large operation centres and factories in the country. Regardless of direct contributions, their presence is always felt with regard to decisions in tobacco regulation.

Different campaign messages: protection of all people against second-hand smoke vs no to an absolute smoking ban

The opponents asked citizens to reject an “absolute ban of smoking”; their approach was clearly to confuse citizens about the real purpose of the initiative, relying on the capacity of emotionally loaded campaign slogans to influence the choice of voters. Posters asking to vote against an “absolute” ban on smoking were present throughout Swiss cities (fig. 2); the opponents explained their slogan by saying that if the proposed ban were to pass, the next step would be a complete ban on smoking, making theirs the fallacious slippery slope argument customarily used in pro-tobacco rhetoric. Finally, the opponents often used the term “extremist” to qualify the proposed ban, while they qualified their own position as “reasonable” – they chose the sentence “let us remain reasonable” for the address of their website (‘vernuenftig-bleiben.ch’ for the German version of the site, ‘restons-raisonnables.ch’ for the French version and ‘siamo-ragionevoli.ch’ for the Italian version). Actually, the initiative was not excessive, as it proposed only a partial implementation of WHO recommendations and FCTC guidelines (which exclude dedicated smoking rooms and require 100% smoke free indoor environments, while the initiative tolerated smoking rooms without service and smoking in individual offices in the work environment); the law proposed by the initiative was already in force in eight of the Swiss cantons and in many neighbouring countries (notably France). However, opponents managed to reframe the purpose of the initiative in such a way that the decision was, for many voters when they cast their ballot, no longer a smoking ban in hospitality establishments and in work places but a proposal to ban smoking altogether. According to the government sponsored election survey [13], smokers largely rejected the initiative; their main cited reasons for doing so were a fear of restriction of personal freedom and a rejection of excessive bans.

Federalism

15 of the 26 cantons had already introduced stricter cantonal laws: 8 had adopted a very similar smoking ban to the one proposed by the initiative and 7 had smoking bans which allowed dedicated smoking rooms with service but excluded smoking establishments. Interestingly, even the cantons with similar laws to the initiative in place, with the exception of Geneva, voted against the current initiative. One could at first imagine that these stricter measures are not popular in the cantons where they were introduced; this is not the case. A survey undertaken by M.I.S. Trend in the canton of Valais one year after their comprehensive smoking ban of July 2009 showed that 81% of the population was satisfied with the ban, including 53% of smokers. A study undertaken by GfK in the canton of St. Gallen 2 years after their ban revealed that 89% of the population was satisfied with it, including 68% of smokers. Finally, a similar study, also by M.I.S. Trend, in the canton of Geneva two years after the ban revealed that 90% of the population, including 54% of smokers, were satisfied that public establishments were smoke-free, demonstrating that with time, smoking bans become increasingly accepted by the population. Geneva accepted the initiative by a small margin of 51.8% whereas every other canton voted against it. Overall, the level of rejection of the initiative by the cantons was inversely correlated with the current level of protection against passive smoking they currently had (fig. 3). A major argument of the opponents was that by imposing a federal law, the cantons would lose their autonomy, which they value as very important. Federalism has been of central importance in the governance of Switzerland since the founding of the modern state in 1848. This federalist state structure affects many aspects of public policy, such as schooling, health care and the tax system, which are different from one canton to the other. Article 3 of the Swiss constitution states that “the cantons are sovereign insofar as their sovereignty is not limited by the federal constitution; they shall exercise all rights which are not transferred to the confederation”. Health in many respects is still largely a cantonal responsibility. It should be noted, however, that the federalist argument had surprisingly little weight in the motivation of voters, whether they accepted or refused the initiative, and played virtually no role in the outcome of the vote. According to an election survey [13], only one quarter of the voters who were in favour of the initiative invoked the need for a federal harmonisation of the smoking ban, while smokers, who overwhelmingly rejected it, paradoxically invoked this argument in much greater proportion.

Lack of support for the initiative by the Swiss government and parliament

During 2012, the Federal Council (the Swiss government) and the parliament both refused to support the initiative or offer an alternative proposal. Two months before the vote, every Swiss citizen was sent a booklet containing the recommendations of the Federal Council [14] with the arguments both in favour of and against the initiative. However, the government’s conclusions in the brochure were essentially based on the arguments made by the opponents of the ban. The government claimed that the current legislation already protects the population from second-hand smoke adding that many fundamental improvements had been achieved as “the vast majority” of the population and employees were no longer exposed to other people’s smoke and that some tobacco related diseases were on the decline. They also mentioned that the current law had only been introduced in 2010, that it was a good compromise obtained after much deliberation by the two chambers of parliament, and that many positive achievements could already be observed; they argued that it would be premature to change a new law so soon after it had been put in place and that people should wait to see if the situation continues to evolve positively. They however failed to mention the “minority” of employees (about 30,000) who are not protected by the current law and must continue to suffer the ill effects of exposure to second-hand smoke.

Their other claims were that the current law respects the principle of federalism important for Swiss tradition, that the initiative would force the Federal Council to establish an ordinance within six months that would remain in place until the parliament adjusted the current federal law, observing that such a practice of changing the law frequently would be unnecessarily burdensome, and finally that the initiative went too far and was not flexible enough – citing the example of an employee who smokes in his personal office without exposing anyone else who would not be allowed to do it anymore. This last example was actually misleading, since the proponents of the initiative had since the beginning of the campaign repeated that their only demand was the protection of the population from exposure to second-hand smoke and that employees who smoked in personal offices without anybody else being exposed to their smoke would not be subjected to the ban.

Difficulties in applying initiatives

In Switzerland, citizens can demand, by an initiative, that a modification of the Swiss Constitution be put to a vote. In order for the initiative to pass, it must first gather 100,000 Swiss petitioners within 18 months. However, of the 182 initiatives submitted to the vote of Swiss citizens since 1893, only 19 passed the double requirement of being accepted by the majority of the population and by the majority of the cantons. The application of these initiatives can be problematic and two recently approved ones, the 2010 initiative “for the automatic expulsion of foreign criminals from Switzerland” and the 2012 initiative “to stop the endless construction of second homes” have faced numerous obstacles in their implementation, which have rendered them practically ineffective. The difficulties in applying these initiatives had been discussed in the media quite extensively in the time leading up to the September 2012 vote. The current initiative for the smoking ban was criticised by the opposition and the government because it implied that the Federal Council would have to establish a transitional ordinance within six months that would remain in force until the parliament would modify the law on the protection against second-hand smoke. They claimed that this procedure was unusual and that it would lead to a great deal of unnecessary complexity, both in the elaboration of the law and in its implementation, making the initiative yet another difficult one to apply, should it pass.

Not enough time for campaigning

On 16 May 2012 the Federal Council set the date for the vote to 23 September 2012. The campaign for the initiative was launched on 13 August 2012 leaving it just over a month to convince Swiss citizens of the importance of the health issue at stake. Unfortunately, this was insufficient time for a full-fledged campaign; an election survey revealed that the health issues at stake were not well understood by the population [13].

Lack of support from the press

Since 1964 Switzerland has forbidden advertisements for tobacco products on television and the radio; however, all other forms are permitted, with regional exceptions. Swiss citizens even voted against a constitutional initiative to ban advertising of all tobacco products in November 1993 [15]. As a result, tobacco advertisement remains one of the main sources of revenue for the written press in Switzerland. It has been demonstrated that cigarette advertising in magazines is associated with diminished coverage of the hazards of smoking [16]; this was clearly the case in the time leading up to the vote. The Swiss Association for Smoking prevention analysed the written press during the four months following the collection of signatures for the initiative and found that out of 999 contributions regarding the smoking ban, only 91 were in its favour whereas 263 articles were against it [17]. We counted the number of campaign ads placed in the largest free newspaper in the country, “20 Minuten”, from mid-August until 23 September 2012 and found 124 supporting the ban vs 68 against it. Direct advertisements during this short period were insufficient to change the opinion of the reader base.

Current federal law from 2010

The current federal law for the protection against second-hand smoke allows dedicated smoking rooms with service in hospitality venues and also smoking establishments of a surface area equal to or under 80 square meters, provided the employees accept to work in these conditions and that this is stated in their employment contract. According to the government, this law was reached as the result of a compromise which followed extensive discussions for many years in the Federal Chambers. A study of second-hand smoke exposure in the Swiss population from 2001 until 2011 [18] showed that whereas in 2001/2002 87% of the population was exposed to second-hand smoke in hospitality venues, 60% of whom for more than one hour per week and 30% for over 3 hours a week, in 2010 these numbers dropped to 36%, 13% and 3%, respectively. In 2009, before the federal ban took place, but after many local cantonal bans, 52% of the population was exposed to second-hand smoke in hospitality venues, 36% of whom for more than one hour per week and 13% for over 3 hours a week. The current federal law therefore led to a dramatic improvement in second-hand smoke exposure; however 28% of the population was (and is) still exposed to second-hand smoke at work [18].

Another point of interest is that the population is aware of the limits imposed by the current legislation. New legislation, as demanded by the initiative, carries uncertainties in its limits as exposed by the campaign and the many, arguable false, claims used by the opposition as arguments. The main points of uncertainty that were brought up in the debates were if an employee would be allowed to smoke in his individual workplace if no one else is exposed and if unstaffed smoking rooms would still be allowed.

Perception from the population / poor comprehension of health issues

On the same day, 23 September 2012, the Swiss population was also asked to vote for other political issues. Despite the tobacco initiative having raised a vivid discussion, it was judged by the population to be the least important issue [13]. Studies show that even in high income countries such as Canada, the UK and Australia, almost half of smokers do not recognise that their smoking can cause cardiovascular disease in those who breathe their smoke [19]. The majority of the Swiss population is aware of the ill effects of second-hand smoke as 98% believe that regular inhalation of smoke is harmful for children, 85% that is responsible for eye irritation and cough, 89% that it increases the risk of developing asthma or bronchitis, 80% that it increases the risk of lung cancer. 77% believe that second-hand smoke increases the risk of myocardial infarction and 72% that it can have deadly consequences [18]. Despite this, 56% of those interrogated still believe that second-hand smoke is less harmful than air pollution [18]. The initiative was launched by the Swiss Lung Association with the support of the Swiss Cardiology Foundation, the Swiss Cancer League and the Swiss Medical Association among others and a call for physicians to be vocal lobbyists was made [20]. However, a portion of the Swiss population is weary of physician backed policies and, for example, due to low vaccination rates (only 75% of children received two doses of measles vaccine) there were more than 4,400 declared cases of measles in Switzerland from 2006 to 2009, more than any other European country [21]. A 2012 survey by the Federal Office of Public Health showed that of the parents that didn’t vaccinate their children by the age of two, 50% were against the measles vaccine and close to 20% were not convinced of the usefulness of the vaccine [22]. Interestingly, the vaccination coverage map by canton is similar to that of the proportion of people who voted for the initiative, although this could be attributed to the fact that traditionally the French and Italian speaking cantons are more open to initiatives addressing public health issues.

A survey showed that people who accepted the initiative were politically more inclined to the left, had higher confidence in federal authority, were younger, had higher educational status and were French speaking [13], although this last point is probably because the majority of French speaking cantons had already accepted stricter local regulations.

Loss aversion

The campaign for the initiative was mostly framed positively in terms of the gains that its adoption would bring (better protection against passive smoking, equity among hospitality workers, national legislative coherence), while the campaign of the opponents was framed negatively, putting forward losses (loss of freedom, loss of revenue, loss of cantonal independence). Prospect theory [23] has shown that when people evaluate gains and losses, at equal objective values, losses take a much greater subjective importance than gains: people have an aversion for losses and a substantially larger gain is needed to compensate for a loss.

This offers another highly plausible reason for the failure of the initiative. For most voters, at the individual level, the gains resulting from the initiative were small, if not insignificant. In the French speaking cantons, current local laws were already providing the same level of protection. For cantons which had not adopted local laws, the federal law had represented large gains, which provided what most citizens considered an acceptable degree of protection. Although the motivations of its promoters were legitimate both on health and equity ground, the initiative only filled gaps. This was probably perceived by most voters not to be enough to compensate for the scary losses announced by the other side, even assuming that these were just hypothetical. The predicted losses were of course highly exaggerated and resulted from distorting the initiative beyond recognition, a typical straw man argument. However, as the stake was not high in the mind of voters, who were called to the polls to decide also on other matters perceived as more important, it is likely that a large part of them based their decision simply by making theirs the campaign slogans and followed the voting directives issued by political parties, without trying to form their own independent opinion.

The above explanation seems contradicted by the fact that the initiative received greater support in the cantons which already had stricter passive smoking regulations in place, i.e., support was greater in those cantons where the expected gains were the smallest. However, in those cantons, the second-hand smoking issue had been debated publicly quite extensively when the local regulations had been introduced, which rendered the opponents’ arguments less effective, as many people had already formed an opinion on the issue and also as they had actually experienced a stricter smoking ban for some time.

Not only were the gains brought by the initiative relatively small, these gains were also not well communicated to the public (perhaps because they were not easy to communicate simply). While its aim was to fill gaps left by the federal law, this was not clearly explained or was explained in terms that were too general, such as “A Switzerland without passive smoking.” Furthermore, in newspaper adverts and on outdoor billboards, the slogans used by the proponents of the initiative were put inside a thick black rectangular frame, mimicking the frames used for textual health warnings on cigarettes packs (fig. 4). People expect to see negative messages inside such frames – such as “Smoking kills” – and, as such messages get very repetitive, they no longer read them, as the result of a “wear-out” phenomenon well known in advertising, which has been found to also apply to textual health warnings on cigarette packages [24, 25]. This rather unfortunate graphic design decision further weakened the positive impact of the message.

Conclusion

The Swiss initiative for a comprehensive ban on smoking failed for many reasons. The dangers of second-hand smoke are now well documented and even the tobacco industry recognises them. On Philip Morris International’s website it is written: “Public health officials have concluded that second-hand smoke from cigarettes causes serious diseases in non-smokers, including lung cancer and heart disease. We believe the public health conclusions on second-hand smoke are sufficient to support smoking restrictions in public places.” However, despite this, a large part of the population is not aware of the effects of second-hand smoke or trivialises them. Powerful interest groups oppose science based prevention and also exert a considerable influence on the population as exemplified in the campaign. The debate got shifted to the very existence of smokers and away from the important health issues.

The 2010 country-wide partial smoking ban that was developed as a compromise is also partly to blame for the initiative’s failure. One can wonder if it is better not to accept anything but a comprehensive ban which could take longer to implement or a partial one that can be accepted more rapidly with the risk of greatly postponing – or pre-empting, as the tobacco industry says – a comprehensive ban. Comprehensive smoking bans are spreading throughout Europe and the world and are necessary for the ratification of the WHO FCTC. It seems inevitable that one day Switzerland will be graced with such a ban. It may need to be achieved through Switzerland’s beloved federalism and be voted for by each individual canton.

Another point that can be criticised with the present initiative is the lack of precision in the demanded ban. This allowed a shift in the debate on many topics that were not supposed to be an issue, such as smoking in individual offices, and wasted much needed time and energy which should have been used to explain to the population the health benefits of a comprehensive ban.

When decisions related to public health issues are put to popular vote – or put to debate by a legislative body – they should be carefully framed. While the positive aspects of the decisions should be made very explicit and put forward in an assertive manner, it is also important to identify the negative arguments which opponents may use and find ways of neutralising them. Controlling both sides of the issue prevents opponents from occupying the ground on the negative side. In the case examined in the present paper, the promoters of the initiative should also have presented its rejection as a loss, making the psychological phenomenon of loss aversion play in their favour.

Finally, the failure of the Swiss comprehensive smoking ban should be instructive for other countries as they set out to regulate second-hand smoking.

Funding / potential competing interests: No financial support and no other potential conflict of interest relevant to this article were reported.

Correspondence

Correspondence: André-Dante Durham, Department of Ambulatory Care and Community Medicine, Lausanne University Hospital, Rue du Bugnon 44, 1011 Lausanne, Switzerland, andre.durham[at]chuv.ch

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