In this issue of Nicotine & Tobacco Research, Hammett et al.1 describe a secondary data analysis in which they compared high versus low stigma groups (based on a median split of respondents’ scores from an adapted version of the Mental Health Consumers’ Experience of Stigma Scale2) in the context of a randomized clinical trial. They sought to examine the relationship between smoking-related stigma and participant characteristics and to evaluate the role of smoking-related stigma on abstinence in proactive versus usual care interventions for tobacco dependence.
It is reasonable to assume that smoking-related stigma is the result of the public health community’s efforts to reduce smoking, in part, by denormalizing tobacco use. These efforts were designed to counter the tobacco industry’s attempts to influence social norms about smoking3 and have been associated with substantial decreases in smoking prevalence over the last several decades.4 Indeed, Hammett et al.1 found that those with greater perceived smoking-related stigma were more likely to receive advice to quit, more likely to receive cessation care from their physician, and more likely to have social support for quitting. Greater stigma at baseline was also associated with greater motivation to quit based on the Contemplation Ladder,5 greater likelihood of making a quit attempt, and greater use of cessation treatments in the past year. The Hammet et al.1 data appear to provide additional evidence that denormalization efforts have produced the intended effect on public health.
A presumably unintended consequence of denormalization efforts is that they may have also stigmatized smokers themselves,6 thus adding harm. For example, while causality should not be assumed, Hammet et al.1 found that greater perceived smoking-related stigma was associated with greater depression and anxiety scores on the Patient-Reported Outcomes Measurement Information System Instrument.7 Others6,8,9 found smoking-related stigma to be associated with shame, guilt, and increased likelihood of hiding one’s smoking status from their health care providers. If denormalization efforts both benefit and harm smokers, a larger discussion of the risk to benefit ratio is warranted.
To begin that discussion, it is important to note that the greatest proportion of the remaining smokers are of low socioeconomic status and/or suffering from mental health problems.10 Denormalization and stigmatization of smoking (and smokers) has clearly been successful in reducing tobacco use, albeit in a disproportionate manner. We must therefore at least consider the ethical ramifications of increasing stigma in already disenfranchised groups.11 At minimum, we must focus more on efforts to provide better, more accessible treatment options, which are likely to result in lower smoking prevalence in the remaining smokers without further marginalizing these groups as nondesirable.
Funding
This work was supported by NIDA R21DA041163 awarded to MLS.
Declaration of Interests
MLS has consulted for Pfizer, Inc.
References
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