New policy of people-first language to replace ‘smoker’, ‘vaper’ ‘tobacco user’ and other behaviour-based labels

Tobacco Control has long recognised the power of language in defining and framing the commercial tobacco pandemic.¹ Language shapes our understanding of health behaviours, and the contexts in which they occur. As the tobacco control research field evolves, so too does our shared language. This helps the public health community to frame issues based on evidence, ensure precision and resist tobacco industry-preferred narratives in favour of more neutral terms,² as well as making visible to the public and policymakers the forces driving the tobacco pandemic. Perhaps most importantly, it highlights that the commercial tobacco pandemic is not merely the result of individual behaviour choices, but rather reflects systems failures by governments¹ which created and perpetuate exceptionalism for the tobacco industry, allowing it to continue to ply the deadliest trade in human history.

It is in this spirit that Tobacco Control is instituting a new policy of people-first language when referring to people who use tobacco and related products. Terms such as ‘smoker’, ‘vaper’ and ‘tobacco user’ (and their various iterations) should no longer be used as general descriptors. Henceforth, our author guidelines will specify placing people before product use for all tobacco and nicotine products. Guidance for, and examples of, appropriate terminology is included in the policy which can be viewed at: https://tobaccocontrol.bmj.com/pages/people-first-language-policy.

People-first language has been widely adopted in relation to people living with conditions such as HIV infection, diabetes, mental illness, epilepsy, obesity and substance use disorders. As highlighted by Goodwin and Walker,³ continued use of the term ‘smoker’ in tobacco control lags other areas of public health, particularly substance use disorders, where terms such as ‘alcoholic’, ‘drug abuser’ and ‘addict’ have long been supplanted by terms that foreground people’s humanity. Person-first language is specified in policy guidance by many professional organisations such as the American Medical Association⁴ and some governments.^{5 6}

Reducing stigma

Tobacco use shares characteristics with some of the conditions listed above, including experiences of stigma.^{7 8} Denormalising the tobacco industry and use of its products is an essential element of tobacco control. However, it is important that the behaviour is decoupled from the person. A useful conceptualisation which has been proposed is that behaviour is malleable, while identity is (largely) immutable.⁹ Labelling people as smokers or vapers suggests the behaviour is an immutable characteristic, an essential identity. When the behaviour is bound up in identity, it can become a target for overt discrimination.⁹ Given how effectively smoking has been denormalised in many countries, assigning smoking as a personal attribute is inherently stigmatising. In jurisdictions with comprehensive tobacco control policies, smoker stigmatisation is such that ‘smoker’ is increasingly shorthand for a range of undesirable personal characteristics.¹⁰ This is particularly salient given that smoking frequently intersects with other stigmatised identities,¹¹ class¹² and socioeconomic disadvantage,^{13 14} and concerns about the role of stigma in creating and perpetuating smoking disparities.¹⁵

It is also important that most people who smoke started as children. Stigmatising people based on initiation of addictive product use before they had full understanding of the consequences or could consent is highly problematic. This labelling persists in marking and defining people by their smoking status even if they no longer use tobacco products (eg, ex-smoker or former smoker)⁸ or have never done so (eg, non-smoker or never-smoker). In contrast, language which does not essentialise the behaviour opens the way for recovery, recognising that people often move along a spectrum of tobacco use.

Commercial determinants of health: resisting industry narratives

Tobacco Control is concerned with the structural factors and policies that maintain or curtail the tobacco pandemic. The tobacco industry has long preferred to foreground individual behaviour,¹⁶ obscuring the fact that ‘smoker’ identity is one which is manufactured for profit. It diverts a person from a life free from nicotine addiction to one of increased risk of disease and premature death. A person-first language policy contributes to subverting the power of corporate interests to foreground and reify individual behaviour as an essential and central component of individual identity. Tethering identity to a commercial product benefits the tobacco industry to the detriment of public health. If ‘smoker’ (or iterations thereof) is an inherent identity, it provides a basis for arguing against some tobacco control policies on the premise that smokers are subject to discrimination and other unfair treatment.

In countries with advanced tobacco control policies, the majority of people who smoke both regret starting and would like to stop.¹⁷ However, the same is not necessarily true for people who use e-cigarettes, particularly given the diverse policy approaches and public attitudes to e-cigarettes globally. With knowledge of the potential harms of e-cigarette use in its infancy—particularly for people who have never smoked—public health should not reify identity-focused language around ‘vaping’.

Descriptive precision and accuracy

Apart from reducing stigma and countering the tobacco industry emphasis on individuals, the terms ‘smoker’, and increasingly ‘vaper’, are scientifically imprecise and lack universally agreed definitions⁸ as well as direct equivalents between languages.³ This is particularly problematic for e-cigarettes, with the rapid changes in device types and contents.² People who use tobacco and nicotine products may not self-identify as smokers, vapers or ‘users’, an issue which has previously been noted particularly in relation to people who do not smoke daily.¹⁸ This imprecision also applies to classifying people as ‘former smokers’,⁸ as well as people who use other products.

Recommended language has implications for data collection and targeting tobacco-free efforts towards specific groups. Williamson et al ⁸ urge researchers and clinicians to use questions that target smoking behaviour, such as ‘have you smoked, even a puff, in the past 30 days?’ Similarly, they suggest avoiding questions that require adoption of a smoking identity such as ‘are you a current smoker?’ They also note that person-first terms can be used when categorising study participants according to current or previous smoking status (eg, ‘people who never smoked’ rather than ‘never smokers’, ‘people who smoke every day’ rather than ‘daily smokers’ and so on). We agree, and encourage all tobacco control researchers to consider using definitions and terms which apply these principles as a matter of good practice.

Challenges

Implementing this policy will be challenging, and will take some time, not least because at Tobacco Control, we already have in the pipeline many accepted online-first papers using the terms smoker and/or vaper. Other papers in progress may have collected data using terms such as smoker, tobacco user, vaper or variations thereof. Copyeditors will need updated guidance. Authors will be anxious about word counts, but careful editing can address these issues. As Williamson et al note,⁸ studies which explore ‘smoker identity’ may occasionally render use of the term unavoidable.

Changing social identity can play a role in smoking cessation pathways (Notley and Collins¹⁹) and identifying as a ‘non-smoker’ can be empowering and affirming. Conversely, some people who smoke and/or vape may wish to claim the identity of ‘smoker’ or ‘vaper’. This may be seen as aligning with efforts by some groups to counter stigma and reclaim positive identities, such as movements to reverse fat-shaming, particularly for those for whom social exclusion risks entrenching their smoking identity.²⁰ However, people-first language does not invalidate how people may choose to self-identify. It provides a broader conceptualisation which reduces the potential for stigma, resists tobacco industry narratives and promotes greater precision and accuracy, as well as creating space which recognises these self-claimed identities can change.

Conclusion

Despite these challenges, we consider this is an important and necessary step. As authors and editors, we should not assume smoking status or other nicotine or tobacco product use as a primary or fixed identity. Our aim is to ensure the terms ‘smoker’, ‘vaper’ and ‘tobacco user’ will become rare in Tobacco Control. Humanity should always come before the interests of the commercial tobacco industry. Our language should reflect this.

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