Should we stigmatise smokers?

Many public health institutions advocate the denormalisation of tobacco use and aim to change social norms around smoking, in an effort to reduce smoking rates and combat the negative effects of tobacco use. These approaches include warning labels and plain tobacco packaging, media campaigns and smoke free policies.

Whilst these interventions are often beneficial in terms of reducing incidence and prevalence of smoking (smoking has decreased substantially over the past decade), they may also serve to marginalise some smokers.

Little is known about how individuals who smoke cope with smoking-related stigma arising from prevention and cessation strategies. One concern is the potential for individuals to internalise public stigma, referred to as self-stigma. Theoretical models suggest that self-stigma may lead to the adoption of perceived negative stereotypes which result in consequences such as a lack of self-efficacy and a loss of self-esteem.

A recent systematic review published in Social Science and Medicine aimed to examine smokers’ self-stigma and the potential consequences on their smoking behaviour. This blog aims to add to the running theme by the elves, examining the impact of stigma across mental health disorders.

Do public health anti-smoking campaigns risk marginalising some smokers?

Methods

The authors searched a number of databases for articles related to tobacco smoking self-stigma in June 2013. They also examined reference lists of articles and contacted expert stigma researchers to ensure they obtained a thorough review of the literature.

The search criteria were:

Original data based articles
Published in English, German, Portuguese or Spanish
Articles that dealt, totally or partially, with tobacco smokers self-stigma.

Results

The searches identified 570 potential articles, of which 30 were included in the systematic review. Eighteen of these studies were qualitative and 13 were quantitative (one was mixed methods).

Findings were categorised into stages represented in a progressive model of self-stigma, which included: (1) stereotype awareness, (2) stereotype agreement and (3) applying stereotypes to oneself.

Stage 1: stereotype awareness

The majority of studies at this stage were qualitative (N=17) and addressed smoker’s awareness of smoking-related self-stigma. These stereotypes were almost universally negative.

30-40% of current smokers felt high levels of family disproval and general unacceptability
27% perceived differential treatment due to their smoking status
39% reported that people think less of smokers, with smokers being rated less favourably than non-smokers.

Within the quantitative studies, many smokers reported not only awareness of stereotypes but also feeling stigmatized for their smoking status.

Stage 2: stereotype agreement

Personal agreement with perceptions and stereotypes was not frequently addressed (studies = 9):

The majority of studies found exclusive agreement with negative stereotypes
A number of studies demonstrated that smokers only applied negative stereotypes to a subset of smokers (older and heavier smokers, or those who smoked around children)
One study reported smokers’ awareness of negative stereotypes, but disagreement and contesting of the stereotypes

Stage 3: application of stereotype and subsequent consequences

Almost all studies addressed the third stage of applying the stereotypes to one’s self and the consequences arising from this:

Participants often reported feeling shame, guilt and embarrassment for their own social behaviour. Words such as ‘leper’, ‘outcast’, ‘bad-person’, ‘low-life’ and ‘pathetic’ were often used in reference to their smoking behaviours
Negative consequences of smoking stigma (studies = 4) included relapse, increased resistance to smoking cessation, self-induced social isolation, and increased stress
Positive consequences of smoking stigma (studies = 4) included smoking cessation, decreased risk of (re)lapse and increased intentions to quit.

Further analyses

There were a number of subgroup differences in smoking self-stigma, however due to the small number of studies these should be interpreted with caution:

Those with a higher socioeconomic status experience more stigma and guilt compared to those with a lower socioeconomic status
There were also age differences; older smokers were more aware of smoking stereotypes (particularly older women)

Smokers often reported feeling shame, guilt and embarrassment as a result of their smoking behaviour.

Discussion

This systematic review of smoking stigma provided tentative support for the intended consequences of stigmatising smoking, for example reduced smoking and the risk of relapse
However, there was also evidence for unintended consequences, which included increased stress, social isolation and relapse
This supports findings from mental health research which suggests stigmatization strategies are often ineffective and potentially counterproductive
Future research should examine individual differences which may influence these patterns

There are limitations of this systematic review:

The heterogeneity of studies and with the majority of studies qualitative prevented a formal meta-analysis of the findings
Furthermore, studies were not included based on smoking rates in participants and studies, therefore individual differences in smoking status may play a role in self-stigmatization
The authors were also candid enough to suggest that their search terms (which included words like shame, blame and hopelessness) may have biased their findings towards to negative consequences.

One potential implication of this review is that public health strategies for prevention and cessation may benefit from inclusion of policies that focus on positive reinforcement and treatment, which avoid the stigmatization of smokers. To conclude, there is mixed evidence for smoking cessation on stigmatization, which may provide necessary positive outcomes but also maladaptive negative outcomes.

Stigmatizing smokers may help reduce overall levels of smoking, but it may also marginalise some smokers and increase stress, social isolation and relapse.