Exploring the Evolving Sociocultural Frameworks of Substance Use
From Chocolate to Cannabis

Exploring the Evolving Sociocultural Frameworks of Substance Use

Swiss Arch Neurol Psychiatr Psychother. 2024;175:1326389362

a Department of Forensic Psychiatry, University of Bern, Switzerland
b School of English, University of Sheffield, United Kingdom
c Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Switzerland
d Department of Psychiatry, Faculty of Medicine, University of Geneva, Switzerland
e Addiction Unit, Department of Mental Health and Psychiatry, University Hospitals of Geneva, Switzerland

Published on 10.04.2024


A famed son of Geneva, Jean-Étienne Liotard’s (1702–1789) pastel paintings were epitomised by subtlety and depth [1]. Blending European artistic conventions with influences from his extensive travels, Liotard depicted candid household images from the 18th Century [2]. All this is exemplified in his celebrated piece “The Chocolate Girl” (“La Belle Chocolatière”), painted around 1744, showing a maid offering drinking chocolate for consumption [fig. 1].
Figure 1: The Chocolate Girl. Jean-Étienne Liotard. circa. 1744–1745. Pastel on parchment, 82.5 cm × 52.5 cm. Public domain. Old Masters Picture Gallery (Gemäldegalerie Alte Meister), Dresden, Germany.
Liotard’s scene is grounded in an Enlightenment period where chocolate provoked contentious debates, akin to other substances today. Its luminosity aside, considering “The Chocolate Girl” in modern settings invites a broader reflection on the dynamics surrounding substance use and how these may shape policy-based and sociocultural responses, especially in relation to current cannabis debates in Switzerland.

Changing Societal Perceptions about Substance Use and Their Complex Determinants


In the Age of Enlightenment when Liotard was painting, the availability of chocolate was expanding across European societies, eliciting criticism and even moral panic reminiscent of coffee and tobacco [3]. These dialogues encompassed religious ideologies with divergent Protestant and Catholic standpoints on whether drinking chocolate was permissible during fast [2, 3]. Further, certain physicians highlighted negative health outcomes from the stimulant properties of chocolate [3].
In the authors’ opinion, Liotard’s focus on the serving girl, with consumers missing from the frame, perhaps gestures towards this contentious status insinuating hidden and illicit undertones without taking an explicit position.
Conversely, at this time, others championed the therapeutic advantages of chocolate. In some regions, chocolate was deemed helpful for digestive issues and a variety of medical conditions including anaemia, gout and tuberculosis [4]. Throughout the centuries, chocolate would gain mainstream acceptance and become extensively commoditised [5], demonstrated by its almost universal accessibility.

Alcohol, Heroin and Psychedelics

The evolving attitude towards chocolate resemble the alternating societal trajectories of other substances. For example, alcohol has been consumed for different purposes throughout history but its moral, social and health perceptions have fluctuated [6]. Specifically, in medieval and post-medieval Europe, alcohol has been deemed to contain selected health benefits [7]. Yet, messaging from 19th and 20th century temperance movements emphasised its detrimental effects, resulting in prohibition in the United States (US) and European countries like Iceland and Finland [8].
Similarly, morphine-based substances and other opioids have frequently been prescribed as medicine and at times, used recreationally [9]. However, as evidence demonstrating their addictive and harmful impact has developed, so have societal patterns. The recent opioid crisis in the US underlines this, and across distinct jurisdictions, illicit heroin use has been both punitively controlled and to a lesser extent, commercially appropriated [10, 11].
Similarly, psychedelics have generated both intrigue and controversy. Used in religious and spiritual contexts and traditions, possible therapeutic applications for psychedelics attracted scientific attention in the early- to mid-20th century, before they were socio-politically stigmatised, politicised and criminalised during the “war on drugs” in the US [12]. This impeded clinical trials, though lately there has been a substantial resurgence in research and interest in their medicinal potential, particularly for mental disorders [12]. Notably, the Australian drug regulator allowed for the prescription of psychedelics for treatment-resistant depression and post-traumatic stress disorder, sparking a range of supportive and opposing sentiments about their safety [13].

Notions of Risk and Harm

As illustrated throughout history, views on substances do not always align with established scientific notions or risks. Despite its well-documented and extensive consequences, alcohol has become ingrained within Western sociocultural practices and is legal in most parts of the world [14].
Significantly, alcohol consumption is linked with global disease and injury burdens, social and economic costs, elevated mortality and disability rates, and other deleterious outcomes [15]. Its associated dangers notwithstanding, alcohol intake remains high throughout Europe (although, this could be changing in some countries as suggested by Swiss data [16]). Interestingly, alcohol and its multivarious connotations also preoccupied later European artists after Liotard. For instance, like “The Chocolate Girl”, Vincent Van Gogh’s (1853–1890) “Café Table with Absinthe” (1887) foregrounds the substance with the consumer being absent from the scene [Image 2].
Figure 2: Café Table with Absinthe. Vincent Van Gogh. 1887. Oil on canvas, 46.3 cm × 33.2 cm. Public domain. Van Gogh Museum, Amsterdam, Netherlands.
In contrast, heroin consumption with its substantial harms, is generally prohibited and remains widely marginalised and stigmatised, even by some healthcare professionals [17]. This has created barriers for drug policy advances and sufficient treatment for individuals with substance use disorders, who have pronounced vulnerabilities for psychiatric and somatic comorbidities [17, 18].
Returning to the Enlightenment when Liotard was painting, the positive health-related aspects of chocolate may have been influenced by capitalistic incentives, with a growing consumer base strengthening economic drivers [3]. Taken together, these paradigms all imply a complex and continuous interplay between social, cultural, economic, judicial and political forces in shaping macro-level attitudes towards specific substances.

Contemporary Perceptions on Cannabis in Switzerland: Another Societal Change?

Prompted by Liotard’s work, such considerations may be particularly pertinent in the context of cannabis-related exchanges in 21st century Switzerland, where opinions on its legislative status have become major talking points [19]. This was demonstrated by a 2008 national referendum, in which 36.7% of the Swiss voters voted in favour of decriminalisation [20]. The legalisation of medicinal cannabis in 2011 further amplified the discourse.
In the 2020s, selective recreational cannabis trials have commenced (e.g., in Basel, Bern, Biel, Luzern and Zurich), enabled by formal amendments to the Swiss Federal Act on Narcotics and Psychotropic Substances [21]. To the authors’ knowledge, extensive results from these pilot studies have yet to be reported [22]. Nevertheless, several schemes have incorporated progressive harm reduction principles, including counselling and psychoeducation for safer use [22]. Elsewhere, some Swiss commentators have expressed opposition to cannabis-related initiatives [23].
Regardless of individual beliefs or outcomes from these programmes, this does appear to signal shifts in societal and governmental approaches to cannabis regulation and consumption, aligning with trends in other jurisdictions and resembling patterns around other substances throughout history [24].
For example, prior research determined that lower religiosity, declining punitiveness and changing media narratives have shaped discussions on the legalisation of cannabis in the US [25]. Similar projects exploring macro-level determinants in Switzerland would provide a basis for future research.

Concluding Remarks

Reflecting on Liotard’s “The Chocolate Girl” in modern settings offers a framework for exploring the macro-level factors that underpin the normalisation or marginalisation of certain substances. This could be relevant for contemporaneous cannabis debates in Switzerland, which has seen considerable transformations in public perceptions and legislative approaches. In this regard, “The Chocolate Girl” may offer an educational heuristic for exploring broader complexities around substance use within psychiatric course materials and beyond.
Further, alike other works, “The Chocolate Girl” shows how artistic production contains and articulates trends within the social milieu from which it emanates, displaying an expressive aspect of the consideration of such representations. As cultural productions are often informed by societal trends (and potentially vice versa), it is intriguing to speculate on how future generations will perceive substance use in the 2020s. Specifically, in a comparable guise to Liotard’s painting, one is tempted to wonder how artworks depicting cannabis consumption will be interpreted in three hundred years’ time.
Alexander Smith Department of Forensic Psychiatry, University of Bern, Switzerland
Alexander Smith
Department of Forensic Psychiatry
University of Bern
Hochschulstrasse 4
CH-3012 Bern
1 Baker C. Jean-Etienne Liotard: pastel pioneer. RA Magazine. 2015 Sep 18 [accessed 2023 Sep 21]. Available from: https://www.royalacademy.org.uk/article/liotard-exhibition-pastel-pioneer.
2 Murdoch T. How Liotard’s Chocolate Girl charmed the city of Dresden. Apollo Magazine. 2018 Nov 20 [accessed 2023 Sep 21]. Available from: https://www.apollo-magazine.com/how-liotards-chocolate-girl-charmed-the-city-of-dresden/.
3 Lippi D. Chocolate in history: food, medicine, medi-food. Nutrients. 2013 May;5(5):1573–84.
4 Dillinger TL, Barriga P, Escárcega S, Jimenez M, Salazar Lowe D, Grivetti LE. Food of the gods: cure for humanity? A cultural history of the medicinal and ritual use of chocolate. J Nutr. 2000 Aug;130(8S Suppl):2057S–72.
5 Grivetti LE, Shapiro HY, editors. Chocolate: History, Culture, and Heritage. Hoboken: John Wiley & Sons, Inc.; 2009.
6 Valee BL. The Conflicted History of Alcohol in Western Civilization. Sci Am. 2015 Jun 1 [accessed 2023 Sep 21]. Available from: https://www.scientificamerican.com/article/the-conflicted-history-of-alcohol-in-western-civilization/.
7 Philips R. Alcohol: A History. Chapel Hill (NC): University of North Carolina Press; 2014.
8 Hall W. What are the policy lessons of National Alcohol Prohibition in the United States, 1920–1933? Addiction. 2010 Jul;105(7):1164–73.
9 Hosztafi S. A heroin története [The history of heroin]. Acta Pharm Hung. 2001 Aug;71(2):233–42. Hungarian.
10 Inciardi JA. War on Drugs – Heroin, Cocaine, Crime, and Public Policy. U.S. Department of Justice. 1986 [242 pages] [accessed 2023 Sep 21]. Available from: https://www.ojp.gov/ncjrs/virtual-library/abstracts/war-drugs-heroin-cocaine-crime-and-public-policy.
11 Smith A, Buadze A, Zullino D, Liebrenz M. “Heroin Chic” in 2020s. Swiss Arch Neurol Psychiatr Psychother. 2023 Feb;174(01):33–4.
12 Belouin SJ, Henningfield JE. Psychedelics: Where we are now, why we got here, what we must do. Neuropharmacology. 2018 Nov;142:7–19.
13 Hunt K. Australia ushers in a new era of psychedelic medicine. CNN health. 2023 Jun 30 [accessed 2023 Nov 20]. Available from: https://edition.cnn.com/2023/06/30/health/australia-mdma-psilocybin-psychedelics-medicine-wellness/index.html.
14 Sudhinaraset M, Wigglesworth C, Takeuchi DT. Social and Cultural Contexts of Alcohol Use: Influences in a Social-Ecological Framework. Alcohol Res. 2016;38(1):35–45.
15 World Health Organization (WHO). Alcohol Fact Sheet. 2022 May 9 [accessed 2023 Sep 25]. Available from: https://www.who.int/news-room/fact-sheets/detail/alcohol.
16 Alcohol Use Declined in Switzerland During Pandemic But Better Alcohol Policy Action Is Needed. Movendi International. 2022 Mar 25 [accessed 2023 Sep 21]. Available from: https://movendi.ngo/news/2022/03/25/alcohol-use-declined-in-switzerland-during-pandemic-but-better-alcohol-policy-action-is-needed/.
17 Volkow ND. Stigma and the Toll of Addiction. N Engl J Med. 2020 Apr;382(14):1289–90.
18 Muncan B, Walters SM, Ezell J, Ompad DC. “They look at us like junkies”: influences of drug use stigma on the healthcare engagement of people who inject drugs in New York City. Harm Reduct J. 2020 Jul;17(1):53.
19 Kapp C. Swiss debate whether to legalise cannabis. Alcohol and tobacco pose far greater danger, say advocates of cannabis legalisation. Lancet. 2003 Sep;362(9388):970.
20 Associated Press in Berne. Swiss approve heroin scheme but vote down marijuana law. The Guardian. 2008 Dec 1 [accessed 2023 Sep 25]. Available from: https://www.theguardian.com/world/2008/dec/01/switzerland-drugs-heroin.
21 Tinari S. Swiss cities test controlled cannabis distribution. SWI swissinfo.ch. 2023 Jul 23 [accessed 2023 Sep 21]. Available from: https://www.swissinfo.ch/eng/business/swiss-cities-test-controlled-cannabis-distribution/48673280.
22 Baltes-Flueckiger L, Steinauer R, Meyer M, Vogel M, Walter M. Effects of cannabis regulation in Switzerland: Study protocol of a randomized controlled trial. Front Psychiatry. 2023 Mar;14:1139325.
23 Hechler-Fayd’herbe N. Die Cannabis-Industrie ist schädlich [The cannabis industry is harmful]. Die Weltwoche. 2021 Sep 9 [accessed 2023 Sep 21]. Available from: https://weltwoche.ch/story/die-cannabis-industrie-ist-schaedlich/.
24 Hughes B, Wiessing L, Des Jarlais D, Griffiths P. Could cannabis liberalisation lead to wider changes in drug policies and outcomes? Int J Drug Policy. 2018 Jan;51:156–9.
25 Felson J, Adamczyk A, Thomas C. How and why have attitudes about cannabis legalization changed so much? Soc Sci Res. 2019 Feb;78:12–27.
Conflict of Interest Statement
The authors have no competing interests to declare.
Author Contributions
AS, NG: Conceptualization; writing – original draft; writing – review and editing. AB, DZ, ML: Conceptualization; writing – review and editing.