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Let's Not Wage War on Smokers

Quitting smoking is good. Stigmatizing smokers isn't.

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The praise being lavished on CVS in response to its promise to stop selling cigarettes is as profuse as it is predictable. When the drugstore announced last week that it plans to pull tobacco products as it continues to expand into the health care market, doctors, journalists and even the president applauded. “We came to the decision that cigarettes and providing health care just don’t go together in the same setting,” said CEO Larry J. Merlo. "I congratulate–and thank–the CEO of CVS Caremark, Larry Merlo, the board of directors, and all who helped make a choice that will have a profoundly positive impact on the health of our country," said Obama.

CVS’s decision is only the latest in a string of anti-smoking measures that have gone into effect with almost no pushback. In November, Michael Bloomberg’s bill banning the sale of cigarettes to New Yorkers under the age of 21 was met with near-universal support—even though his campaigns against soda and trans fats became fodder for national debates about individual rights and personal freedom. In December, the traditionally smoker-friendly EU voted to implement stricter anti-smoking regulations, including a total ban on the sale of flavored cigarettes.

The lack of resistance to these policies is a reflection of greater awareness of the health risks of smoking, but it’s also a sign of the stigma that’s come to surround cigarettes and the people who still buy them. Tobacco control policies have played a big role in slashing smoking rates—which have fallen from 56 percent of American adults in 1965 to 18 percent today—but they’ve also stigmatized smokers, forcing them to huddle outside public buildings, bars, and now parks. Stigma can be useful if it deters people from smoking, but it can have nasty side effects—like tempting smokers to hide their habits from their doctors, placing an added burden on already vulnerable populations, and making diagnoses of smoking-related diseases embarrassing (on top of life-threatening). Health care officials know this: that’s why they’ve fought to lessen the stigma attached to other conditions and behaviors, from AIDS to depression. “Stigmatization represented a profound psychological and social burden on those with AIDS or HIV infection and it also fuelled the spread of the epidemic,” wrote Jennifer Stuber and Ronald Bayer in a 2006 paper in the American Journal of Public Health. “Yet, in this instance, the concerns about the impacts of stigmatization have been given little consideration.”

Thanks to anti-smoking crusaders, “The fragrant has become foul,” wrote medical historian Allan Brandt in 1988. “An emblem of attraction has become repulsive; a mark of sociability has become deviant; a public behavior now is virtually private.” More recently, psychologists have found that smokers are seen as “outcasts” and even “lepers.”

When did it become acceptable to give smokers dirty looks?

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For a recent paper in the Journal of Social Policy, Professor Hilary Graham of the UK’s York University charted the changing focus of anti-smoking campaigns.

In the US and the UK, health promotion campaigns were initially focused on the risks to the smoker…From the mid-1970s, the risks to others, and specifically to children born to pregnant smokers, were incorporated into government campaigns… Through the 1980 s and 1990 s, smoking was increasingly recast as a threat to the wider public, a shift in public health discourse that was particularly marked in the US.

In 2006, sociologist Hannah Farrimond and psychologist Helene Joffe asked 40 British adults what they thought about smokers. It wasn’t nice.

Non-smokers use terms such as ‘outcast’, ‘persecuted’, ‘lepers’, ‘under-class’ and ‘blacklisted’ to describe smokers’ status in society….Non-smoking participants associate smokers with a strong negative aesthetic. This comprises two aspects, smell (e.g. ‘reek’, ‘pong’, ‘stink’, ‘stale’, ‘old’) and negative appearance (‘stained yellow fingers’, ‘grey, dry, wrinkly skin’, ‘brown teeth’)…several non-smokers see smokers as lacking in cleanliness and engaging in poor self-care.

And in 2008, Stuber interviewed 816 current and former smokers in New York City.

Most respondents agreed that ‘‘Most people would not hire a smoker to take care of their children’’ (81%) and that ‘‘Most non-smokers would be reluctant to date someone who smokes’’ (72%). The prevalence of the perception ‘‘Most people believe smoking is a sign of personal failure’’ (21%) and, ‘‘Most people think less of a person who smokes ’’(39%), were endorsed less frequently but still indicate substantial stigma. The first two items measure social distance from smokers, whereas the second two items are measures of the devaluation of smokers.

The stigma’s worse for lower-income smokers

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More educated smokers are better at rationalizing their behavior, while smokers of lower socio-economic status are more likely to internalize the stigma. “Smokers’ sense of the social disapproval they face varies as a function of socio-economic group,” Farrimond and Joffe found.

Higher SES smokers tend to challenge the ‘facts’ on which this stigmatization is based, whereas lower SES smokers internalize the stigmatized aspersions…Higher SES smokers also tend to use the pollution metaphor to their advantage to mitigate any perceived blame, by arguing that pollution caused by their personal smoking is equivalent or of lesser impact than other types of pollution…. Higher SES smoking participants also tend to argue that the health risk for passive smokers is relatively low, both in comparison to their own personal risk and in general.

Lung cancer patients feel stigmatized—even if they’ve never smoked

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In 2004, a team of health scientists at Oxford interviewed 45 people with lung cancer and found that felt even more stigma than other cancer patients:

Participants experienced stigma commonly felt by patients with other types of cancer, but, whether they smoked or not, they felt particularly stigmatized because the disease is so strongly associated with smoking… Some patients concealed their illness, which sometimes had adverse financial consequences or made it hard for them to gain support from other people.

In fact, ten percent of lung cancer patients have never smoked, though they may have a hard time getting doctors to believe them: one patient the team interviewed said that doctors refused to believe he’d never smoked, in spite of his own promises and the testimony of his wife.

In a 2008 study published in the journal Clinical Lung Cancer, researchers administered a questionnaire to 172 cancer patients—96 with lung cancer, 30 with breast cancer and 46 with prostate cancer—and found “perceived cancer-related stigma” to be highest in the lung cancer group. “A belief that one caused one's own cancer,” they noted, “is correlated with higher levels of guilt, shame, anxiety, and depression.”