With ashtrays a collector’s item and cigarette breaks relegated to cold and rainy office stoops, it’s almost hard to remember that smoking was once considered James-Dean cool. But its relatively rapid passage from popular to pariah has had some unintended consequences: Public health campaigns that stigmatize smoking can backfire, according to a study published Monday, leading some people to become so angry and defensive that they refuse to quit and others feeling so bad about themselves that they give up trying.
“We weren’t surprised that the stigma hurt some individuals since this has been found to be true for other mental health conditions. However, it was surprising the degree of smoking stigma and the degree to which many smokers reported agreeing with the stigmatizing stereotypes,” said lead author Dr. Rebecca Evans-Polce, a postdoctoral fellow at the Methodology Center and the Bennett Pierce Prevention Research Center at Penn State.
Smokers reported feeling shame, guilt and embarrassment for their smoking behavior and used words such as “leper,” “outcast,” “bad person,” “low-life” and “pathetic” to describe themselves, the study found. These feelings increased after failed attempts to quit smoking.
To be sure, some smokers reported that efforts to “denormalize” smoking – to make it uncool – increased their intentions to quit. But others reported low self-esteem and a sense of hopelessness. Still others resisted internalizing the stigma by adopting a defensive strategy also employed by other marginalized groups such as those with a mental illness or with weight problems, the study said. They became angry at the government and public health advocates for stigmatizing smoking and continued to smoke as a way of defending their self-esteem.
The study, published in the journal Social Science & Medicine, analyzed 30 previous studies to investigate to what extent smokers were aware of negative stereotypes, agreed with them and applied them to themselves. It did not look at the effect of negative stereotypes on nonsmokers.
To Dr. Jonathan Bricker, a psychologist and public health researcher at Fred Hutchinson Cancer Research Center and the University of Washington, the latest meta-analysis confirms the problems with a one-size-fits-all approach to smoking cessation efforts.
“For years, the tobacco control field has believed that stigmatizing smokers will motivate them to quit,” he said. “I have never bought that line of thinking, which flies in the face of what we know from behavioral psychology about the negative consequences of stigmatizing certain groups: shame, self-loathing, and other negative emotions that people cope with by using substances. A lot of smokers are very sensitive to that kind of labeling.”
By many measures, the public health campaign against smoking has been successful. Fifty years ago, 42.4 percent of American adults smoked. Today, 17.8 percent do. The decline is attributed to a mix of efforts, including cigarette taxes, smoke-free air laws, media campaigns that teach kids about smoking’s dangers, and pressure on movies and TV shows not to glamorize smoking. In addition, some employers prohibit hiring smokers or charge smokers higher health insurance premiums.
But while laws and campaigns have helped reduce the prevalence and incidence of smoking and reduced exposure of non-smokers to second-hand smoke, they may have further marginalized the smokers who are left, the new study reported. That’s especially problematic because most of the progress in the national anti-smoking effort has been in preventing younger generations from starting the habit. Only about 4 to 7 percent of people are able to quit smoking on any given attempt without medicines or other help, according to the American Cancer Society.
The study’s findings make the case that “it may be useful, alongside some of the current interventions, to have smoking intervention strategies that also focus on increasing self-efficacy, positive reinforcement and treatment strategies,” Evans-Polce said.
“It’s time to get serious about reworking anti-smoking messaging so that it is targeted to the individuals most likely to benefit from them,” he said.
Bricker studies acceptance and commitment therapy, or ACT, to help people quit smoking and other unhealthy behaviors. Unlike traditional quit-smoking approaches, which focus on willpower and avoiding one’s urges to smoke, ACT focuses on increasing one’s willingness to accept the physical, mental and emotional challenges of quitting while also encouraging commitment to engage in values-based behavior change. For more about ACT, see his TEDxRainier talk.
He recently received a $3.1 million, five-year grant from the National Cancer Institute to conduct a randomized, controlled clinical trial of SmartQuit, a smoking-cessation smartphone app.
In the United States, lung cancer is the leading cause of cancer deaths. It is also one of the most common cancers in the world. The majority of lung cancers are related to smoking.
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Solid tumors, such as those of the lung, are the focus of Solid Tumor Translational Research, a network comprised of Fred Hutchinson Cancer Research Center, UW Medicine and Seattle Cancer Care Alliance. STTR is bridging laboratory sciences and patient care to provide the most precise treatment options for patients with solid tumor cancers.
Mary Engel is a former staff writer at Fred Hutchinson Cancer Research Center. Previously, she covered medicine and health policy for the Los Angeles Times, where she was part of a team that won a Pulitzer Prize for Public Service. She was also a fellow at the Knight Science Journalism Program at MIT. Follow her on Twitter @Engel140.