Widespread Anti-Smoker Stigma Is Harmful, as Well as Wrong

    Adult smokers are a highly stigmatized population, yet people rarely acknowledge that this is the case. The denial of this truth not only makes smokers vulnerable to receiving unequal treatment in society, but impedes their efforts to quit.

    Consider a brief personal anecdote. Recently, a friend mentioned that she has a co-worker with health problems. This co-worker is also a smoker of more than 30 years. The co-worker credits switching to e-cigarettes with eliminating his chronic cough and improving his stamina.

    The friend’s response: “That’s not exactly the poster child vaping needs.” She went on to say it would be more cost-effective for society if the co-worker kept smoking and expedited his death.

    This exchange demonstrates how anti-smoker stigma remains even after a smoker quits or switches to a less harmful alternative. Smoking seems to be one of the few behaviors where making a healthier choice, no matter how small, is met with continued contempt instead of support.

    While this story may seem to describe an unusually harsh viewpoint, it’s far from a rare one. In fact, it’s common enough that the Lung Cancer Alliance felt compelled to run a “No one deserves to die from lung cancer” campaign to decrease the stigma surrounding smoking and lung cancer diagnoses.

    The stigma is even evident among medical practitioners—the people who should be least judgmental of those with health conditions. It is often apparent in the medical treatment smokers receive. One experimental study found that doctors were much less likely to offer a novel, marginally life-extending lung cancer treatment to a smoking patient than to a nonsmoking patient. Another study found that 83 percent of doctors in the United States consider Chronic Obstructive Pulmonary Disease (COPD) a self-inflicted condition.

    Smokers sense the stigma, and it affects their behaviors. In one study, 8 percent of smokers reported not disclosing their smoking status to a medical professional, while others reported delaying care-seeking because of concerns about the stigma surrounding their behavior.

    Perhaps the ultimate hypocrisy is that we condemn smokers for choosing to start smoking, yet we consistently make it more difficult for them to quit than it already is.

    Ordinarily, stigmatizing a disease or observing medical practitioners making decisions based on social characteristics would raise the hackles of the public health community. With smoking, however, this hasn’t been the case. In fact, many anti-smoking campaigns actually turn to stigmatization as a behavioral control tactic.

    While this strategy is correlated with the decreasing smoking rate, the effectiveness of stigmatizing smoking behavior to encourage cessation is still in question and is accompanied by many unintended consequences. One of which is morphing the anti-smoking message into an anti-smoker message.

    This sentiment inevitably bleeds into any conversation about tobacco harm reduction. Anyone who considers themselves a public health practitioner will agree that not smoking—or completely quitting, if a person has already started—is the best health choice one can make. But consensus is quickly lost as soon as reduced-risk tobacco products enter the conversation.

    The anti-smoker mentality lends itself to framing tobacco use as dichotomous: You either smoke cigarettes, or you are a nonsmoker. The reality is that tobacco use patterns exist on a continuum of risk, and stigma minimizes the reality that switching—fully or partially—to a reduced-risk product can significantly decrease the risk of negative health outcomes and improve the odds of later completely abstaining. As an added bonus, smoke-free tobacco products do not present the same secondhand exposure risks as cigarettes—and in the case of products like snus and other smokeless forms of tobacco, the secondhand exposure risk is zero.

    Yet despite the established benefits of reduced-risk products, systemic stigmatization of smoking and smokers has resulted in reduced-risk products being viewed and regulated harshly—often even more harshly than combustible cigarettes. This makes switching to a reduced-risk product less appealing to current smokers. After all, if the cost, perceived risk and social stigma of using a reduced-risk product is equivalent to that of smoking a cigarette, why change one’s nicotine source?

    Perhaps the ultimate hypocrisy of the smoking stigma is that we condemn smokers for choosing to start smoking, yet we consistently make it more difficult for them to quit than it already is. Successful behavior change requires empowerment, and stigma disempowers.

    If we truly want to encourage smokers to quit, we have to meet smokers “where they’re at” and provide options that help them achieve their desired outcome.


    Photo by Rafał Opalski on Unsplash

    • Chelsea Boyd

      Chelsea Boyd, MS is a research associate in harm reduction policy at the R Street Institute. Her work focuses on applying harm reduction to tobacco control, substance use and sexual health policy to improve public health. She received her master’s degree in epidemiology from the George Washington University Milken Institute School of Public Health and her bachelor’s degree in liberal arts, concentrating on economics, from Colorado State University.

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