Recent years have seen the rise of anti-smoking campaigns. While these campaigns are often successful at getting people to quit, Sara Evans-Lacko writes that their negativity can lead to the opposite of their intended effect. She argues that the stigma that such approaches bring can lower smokers’ self-esteem, making it harder for them to quit, or make them angry and want to smoke more.
Anti-smoking campaigns are often praised for their success in reducing smoking and hence their impact on improving the public health of the population. Although there is considerable research on the degree to which anti-smoking campaigns are successful at encouraging individuals to quit and thus reducing overall smoking rates, there can also be negative unintended consequences. Designed to reduce smoking, these approaches could instead undermine the abilities of those affected, particularly those who are most vulnerable, to quit smoking.
Tobacco control policies include a range of approaches, for example, comprehensive smoking bans, media campaigns and pictorial warnings on tobacco products in addition to restrictive anti-smoking policies instituted by some organisations such as prohibiting the hiring of smokers or requiring higher insurance premiums. Alongside increasingly negative public attitudes towards smokers, these approaches can make it harder for people to quit smoking because they become angry, defensive and the negative messages lead to a drop in self-esteem. These types of social control strategies, which are employed in an effort to reduce the prevalence and incidence of smoking and reduce exposure of non-smokers to second-hand and third-hand smoking may actually further marginalize ‘residual smokers’ who may be more disadvantaged and have fewer resources to help them quit.
While not always considered acceptable throughout history, a few decades ago, smokers were revered as “cool,” and “mysterious” invoking images such as the Marlboro Man. However, in recent decades the social status associated with being a smoker has diminished. A review of almost 600 articles suggests that there is good evidence that the public stigma of smoking has increased over the last decades and currently, the stereotypes that smokers deal with are almost universally negative. In multiple studies, smokers used words such as “leper,” “outcast,” “bad person,” “low-life,” and “pathetic” to describe their own behaviour. One study found that 30-40 per cent of smokers felt high levels of family disapproval and social unacceptability and 27 per cent felt they were treated differently due to their smoking status. Another study found that 39 per cent of smokers believed that people thought less of them.
There is broad consensus regarding the impact of smoking on individual and public health and considerable research on the degree to which anti-smoking campaigns are successful in encouraging individuals to quit and in reducing overall smoking rates. Yet, little is known about how those who smoke cope with smoking-related stigma that may stem from these strategies and the negative consequences of smoking-related stigma on those who smoke. Of particular concern are the potential consequences of internalizing public stigma which is referred to as self-stigma or internalized stigma as they are likely to vary for individuals. For example, the public stigma of smoking could result in four potential outcomes for smokers. The desired outcome and the one often assumed by public health practitioners is that smokers will internalize the stigma and quit smoking in order to feel better. However, there are at least three other potential outcomes which can be detrimental: (1) the smoker internalizes the smoking stigma, loses self-esteem and self-efficacy, and fails to quit smoking, (2) the smoker resists internalizing the smoking stigma remaining indifferent and fails to quit smoking, or (3) the smoker resists smoking stigma internalization, may become angry and defensive at the public for stigmatizing smoking, fails to quit smoking and may even increase their self-esteem and self-efficacy regarding smoking.
Overall, our review of the literature found evidence for desired and unintended outcomes. In four studies, negative consequences of smoking self-stigma were exclusively reported. Negative consequences included relapse, increased resistance to smoking cessation or reduction, self-induced social isolation, increases in stress due to non-disclosure of smoking status to one’s healthcare provider. Four studies exclusively reported positive consequences. Positive consequences included smoking cessation, decreased risk of lapse or relapse, and increased intentions to quit. Five studies reported a mix of positive and negative consequences from smoking stigma. Five studies also reported non-significant findings in relation to consequences.
The stigma surrounding smokers leads to a number of different outcomes, including relapses, increased resistance to quitting, self-induced social isolation and higher stress levels. While the evidence shows that stigmatising smoking may prompt some individuals to quit, health policies should focus on more positive strategies, reinforcing the benefits of giving up smoking rather than reiterating negative stereotypes. Currently, there may be an overreliance on strategies which focus on negative reinforcement including strategies to change smoking norms and increase smoke-free public spaces as well as more structurally stigmatizing policies such as basing hiring decisions and health insurance costs on smoking status. Public health smoking prevention and cessation strategies need to emphasise a greater inclusion of interventions and policies that focus on positive reinforcement and treatment in order to reduce smoking prevalence while avoiding the stigmatization of smokers.
This article is based on the paper, “The downside of tobacco control? Smoking and self-stigma: A systematic review” in Social Science & Medicine.
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Note: This article gives the views of the author, and not the position of USAPP – American Politics and Policy, nor the London School of Economics.
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Sara Evans-Lacko – LSE Personal Social Services Research Unit
Sara Evans-Lacko is an Associate Professorial Research Fellow at the LSE’s Personal Social Services Research Unit (PSSRU). She is a mental health services researcher with a particular interest in the role of health services and social support in the prevention and treatment of mental illness. Her research focuses on developing innovative methods to improve access to and quality of mental health care for young people and cross-cultural applications of this in addition to the evaluation of public health interventions such as the Time to Change anti-stigma campaign which aim to improve important changes at the population level.
How do you know what you don’t know you don’t know?
With stigmatisation comes a variety of responses, some highlighted in this article. These are by no means exhaustive and conveniently disregard the independent soul who either frankly and actively disregards most pronouncements from the Ministry-of-We-Know-Best-For-Your-Own-Good or could simply care less. There are indeed very many about. But there is an even more nebulous issue, that of reporting, namely under and over-reporting, the inconvenient unknowable issue that really skews the statistics. It is stunningly obvious to most that a direct consequence of stigmatisation is under-reporting (of “I do smoke”) and over-reporting (of “I don’t smoke.”) Furthermore, quite literally everyone knows that smoking increases a variety of often rather small absolute risks in (an inconvenient) dose dependent manner. Not only is a statement of absolute risk largely ignored (because it is often fairly trivial and fails to compel, particularly at low levels of smoking) but so is a key causal criteria of the relationship between smoking and its potentially deleterious effects, that of dose dependence. Do the risk mongers publicly define a smoker? One a year, one a week, one a day? What? Clearly there is a dose relationship undetectable below the level of ambient particulate pollution exposure to a non-smoking population.
It is politically correct to stigmatise smokers. Pretending anything less merely adds insult to injury. Anti-smokers always fall into their confirmation-bias superiority trap. They actually believe they are smarter and as a result superior. Banning and prohibition always fails mightily. Humans have sought to smoke and ferment since the dawn of time so the message, as with all ‘public health’ messages is doomed to be ceaselessly re-formatted every generation. Doubtlessly, this may help provide endless fodder and funding for social “service” research.
The desired outcome and the one often assumed by public health practitioners is that smokers will internalize the stigma and quit smoking in order to feel better. However, there are at least three other potential outcomes which can be detrimental: (1) the smoker internalizes the smoking stigma, loses self-esteem and self-efficacy, and fails to quit smoking, (2) the smoker resists internalizing the smoking stigma remaining indifferent and fails to quit smoking, or (3) the smoker resists smoking stigma internalization, may become angry and defensive at the public for stigmatizing smoking, fails to quit smoking and may even increase their self-esteem and self-efficacy regarding smoking.
There is another outcome from the attempt to stigmatize:
That the stagmatees find out the truth, that this 2000+ year old agricultural product does not “cause” all of these purported illnesses. TC studies do not include stress in the model. There may be adverse effects from self medication. Bit our current 2 dimensional epidemiological approach will not distinguish between the illness an the (self) medication used to treat the illness. This is a “confounding by indication” error.
And the added stress of false blame just adds to the cumulative stress burden of those who have already had more than their share. More stress is not the answer. Truth heals.
Hi Sara,
one of the best ways to stop stigmatizing smokers would be to encourage Tobacco Harm Reduction. Smokeless Tobacco and Electronic cigarettes are orders of magnitude safer than smoking. Yet many in Tobacco Control are as opposed to Tobacco Harm Reduction as they are to smoking and smokers.
Go figure…
We were stigmatised deliberately. Remember the ads : “If YOU smoke YOU stink” and the myriad of abusive campaigns that ran over a decade as ideological quangos prepared for the blanket smoking ban of 2007 (in the UK) . There is even a viral video made by our NHS that shows a smoker getting beaten violently to death. This kind of campaign is just unacceptable. Not only that, children are being groomed to hate and fear people who smoke with nasty and abusive posters about the “smelly, dirty, skint, disgusting, selfish, pathetic addict smoker” in schools. Also campaigns which suggest that we are employment liabilities, awful tenants, terrible friends, child abusing parents, etc… That is not stigma we have brought down on ourselves. That has been forced upon us. When they say to me : “but you can go in a pub. You just can’t smoke. What’s wrong with that?” I say how can I support a law that I fought against, that I profoundly disagree with, and to go in a pub as I used to, or a cafe to sit and write, or a restaurant for its ambience and atmosphere, which simply isn’t the same without smoke. To do so would be to say I surrender and accept this law. That is never going to happen. Bad laws must be ignored. But don’t blame me as a smoker for being stigmatised. Blame the thugs in industry and public health who funded what has become a hate campaign. If we’re not stigmatised, then let us have our own meeting places indoors where people who don’t like smoke – or fear it – don’t have to go. Until that happens the blame for stigmatising smokers lies with quangos , politically motivated junk scientists and smokerphobic politicians in both local and national Govt. Harm reduction is not just vape sticks or smokeless but also an encouragement of smoking less – dose makes poison and that is a truth. Another truth is that this issue is no longer about health but prohibition and a belief that some people have a right to tell others how they should be living their lives.
You cannot change anyone by insulting or shocking them. Public health is about inclusiveness, wholeness, and health. There should be no judgement in public health only education and advocacy. Thank you for reading my coment, and blessings to all!