Smoking and the emergence of a stigmatized social status

https://doi.org/10.1016/j.socscimed.2008.03.010Get rights and content

Abstract

An increase in the social unacceptability of smoking has dramatically decreased tobacco use in the USA. However, how policies (e.g., smoke free air laws) and social factors (e.g., social norms) drive the social unacceptability of tobacco use are not well understood. New research suggests that the stigmatization of smokers is an unrecognized force in the tobacco epidemic and could be one such mechanism. Thus, it is important to investigate the sources of smoker-related stigmatization as perceived by current and former smokers. In this study, we draw on the broader literature about stigma formation in the context of the tobacco epidemic and examine the role of attribution, fear, tobacco control policies, power and social norms in the formation of smoker-related stigma. We test hypotheses about the determinants of stigma using a population-based sample of 816 current and former smokers in New York City. The results show that perceptions of individual attributions for smoking behavior and fear about the health consequences of second hand smoke are important influences on smoker-related stigmatization. Structural forms of discrimination perpetrated against smokers and former smokers (e.g., company policies against hiring smokers) are also related to smoker-related stigma. Respondents with more education perceive more smoker-related stigma than respondents with less education and, Black and Latino respondents perceive less smoker-related stigma than White respondents. Social norms, specifically family and friends' expressed disapproval of smoking, contribute to the formation of smoker-related stigma. These findings suggest important points of leverage to harness the powerful role of stigma in the smoking epidemic and raise concerns about the possible role of stigma in the production of smoking disparities.

Introduction

The increase in the social unacceptability of smoking has had a dramatic impact on tobacco use in the USA (Alamar & Glantz, 2006) especially, in states and cities that have enacted tough tobacco control policies (Frieden et al., 2005, Gilpin et al., 2004). However, how policies (e.g., smoke free air laws) and social factors (e.g., social norms) drive the social unacceptability of tobacco use are not well understood. Possible mechanisms underlying the link between social unacceptability and tobacco consumption include smoke free air in homes, workplaces and restaurants, media campaigns stressing the dangers of second hand smoke, and social norms (see Fichtenberg & Glantz, 2002 as exemplar). A recent study suggests that the stigmatization of smokers may be another mechanism finding that smokers who perceive high levels of stigma are more likely be quitters (Stuber, Galea, & Link, submitted for publication). In this paper, we examine the factors that contribute to perceptions of stigma among current and former smokers using newly developed measures of smoker-related stigma.

We conceptualize stigma as the negative labels, pejorative assessments, social distancing and discrimination that can occur when individuals who lack power deviate from group norms. Stigma is at once a social process of marginalization perpetrated by those who do the stigmatizing and at the same time a condition that stigmatized individuals must navigate. In this study, we focus on stigma perceived by current and former smokers, the persons who are stigmatized. To identify possible social and historical processes that may be at work in the construction of the smoker as pariah, we survey the broader literature on stigma formation in the context of the tobacco epidemic focusing on five theoretical domains as they relate to stigma: attribution theory and stigma, fear or peril and stigma, policy and stigma, power and stigma, and social norms and stigma.

Attribution theory contends when a person is encountered who violates group norms, people attempt to search for the cause of this violation, which in turn, affects their reactions towards that person (Weiner, 1995). The theory predicts that stigmatized conditions believed to be outside the control of the stigmatized person (e.g., a person with HIV/AIDS who contracted the illness due to a blood transfusion) are associated with less blame and anger and with more positive emotions, which in turn leads to an inclination to help rather than to punish (Corrigan, 2000). Following this rationale, perceptions about the causes of smoking may be central to the formation of smoker-related stigma. For most of the 20th century, smoking was regarded as a socially learned habit and as a personal choice. Drawing from attribution theory, we expect that beliefs to this effect will be directly related to perceptions of smoker-related stigma.

Within the last decade our focus on other potential causes of smoking has emerged. Specifically, the role of social stress in causing and sustaining smoking behavior is beginning to be more widely accepted (Jarvis, 2004). We expect that the perception that smoking is caused by stress will be inversely related to smoker-related stigma because the locus of control for the behavior is reframed as determined by external circumstances. Support is also growing for the idea that there is an inherited vulnerability to nicotine addiction (Zickler, 2006). Attribution theory would predict that genetic causal attributions would decrease smoker-related stigma because the shift of control for the behavior is reframed as biological. However, research by Phelan (2005) on mental illness stigma suggests that genetic attributions not only fail to reduce stigmatizing beliefs but also actually contribute to increases in some stigma-relevant domains. She argues that because genetic characteristics are seen as irrevocable, genetic essentialist thinking leads to greater stigmatization when applied to negative valued qualities because it contributes to perceptions that the person is fundamentally different from others, that the problem is persistent and serious, and that the problem is likely to occur in other family members. Thus, we hypothesize genetic attributions for smoking will be positively related to smoker-related stigma.

Fear has been shown to contribute to stigmatizing attitudes towards numerous attributes, health conditions and behaviors such as leprosy (Bainson & Van den Borne, 1998), HIV/AIDS (Herek, Capitanio, & Widaman, 2002) and mental illness (Link, Phelan, Bresnahan, Stueve, & Pescosolidio, 1999). The reasons underlying these fears (e.g., contagion, unpredictability) and the evidence base for them vary for each condition and behavior. Fear about the harms caused by second hand tobacco smoke may be one factor underlying smoker-related stigmatization. Mounting evidence in the 1970s, 1980s and 1990s indicated that smoking is not only a health hazard to smokers, but is also a health hazard to non-smokers. The effectiveness of the second hand smoke movement is emboldened by recognition of the innocent victim such as children with smoking mothers (Brandt, 1998). Thus, we hypothesize that fear about the threat second hand smoke poses to children will be positively related to perceptions of stigma.

The broader literature on social stigmatization identifies two ways that social policy can contribute to stigmatization. First, social policy has been shown to contribute to stigmatization through structural or institutional forms of discrimination. Structural discrimination includes the policies of private and governmental institutions that restrict the opportunities of marginalized groups whether such restriction occurs through intended or unintended consequences of those policies. There are numerous examples of social policy leading to the perpetuation of discrimination and to an increase in stigma perceived by persons of minority race/ethnicity, persons with HIV/AIDS and persons with mental illness (Corrigan, Markowitz, Watson, Rowan, & Kubiak, 2003). Examples of structural discrimination are beginning to emerge in the context of the tobacco epidemic. For example, the American Civil Liberties Union (1998) reports atleast 6000 companies refuse to hire smokers including Alaska airlines, Union Pacific and the World Health Organization. These policies, by sanctioning discrimination, abrogate smoker's rights as “ordinary citizens” by placing “them” in a category that separates smokers from “us” (non-smokers). Our intent here is not to equate what we are calling structural discrimination perpetrated against smokers with structural discrimination perpetrated against other marginalized groups because there are ways in which the former instances of structural discrimination may be justified, for example, with rationales such as employers have to pay more for the health insurance of their smoking employees. Instead, what we are hypothesizing is that the process of separate and lower placement that results from this sort of policy will be positively associated with perceptions of smoker-related stigma among current and former smokers.

A second way that social policies lead to increased stigmatization is through symbolic messages of moral condemnation (Schneider & Ingram, 1993). Policies designed to punish or segregate a designated group of individuals from others may be particularly stigma generating. By this logic, smoke free air laws may also produce stigma. Although smoke free air laws are imposed on the act of smoking and not on a smoker as an undesirable type of person, one need only look outside at the huddle of smokers commonly seen outside public buildings in inclement weather to witness the decreased social standing of smokers relative to non-smokers. Smoke free air laws are proliferating in the USA. By 2007, 49 states restricted smoking in government worksites, 39 sites restricted tobacco use in private workplaces, and forty one states placed restrictions on smoking in restaurants (American Lung Association, 2007). It is not just government that is regulating tobacco behavior. Private industry is also involved in tightening restrictions on work-place smoking (Brownson, Eriksen, Davis, & Warner, 1997) and restrictions on smoking within households are also increasing (US Department of Health and Human Services, 1999). We hypothesize that smokers and former smokers who have greater exposure to (and awareness of) smoke free air laws will be more likely to perceive smoker-related stigma.

Link and Phelan (2001) argue that it is not possible to fully stigmatize, that is to successfully label, pejoratively stereotype, effectively set apart and broadly discriminate against, a particular group unless they lack social, economic or political power relative to the persons who are doing the stigmatizing. From this vantage point, one might argue that the stigmatization of the American smoker has been more smoothly achieved because the socioeconomic composition of smokers has changed in the USA in the last quarter century. The tobacco literature identifies a strong negative relationship between lower educational levels and income, blue collar work, and smoking cessation suggesting there is a strong social contextual component to smoking cessation (Barbeau, Krieger, & Soobader, 2004). While socioeconomic disparities in smoking cessation are not well understood, several factors conceivably linked to stigmatization have been suggested. For example, studies have shown that blue collar workers reside in occupational environments that are less supportive of quitting (Sorenson, Emmons, Stoddard, & Linnan, 2002). A recent study finds that cigarette smoking is related to differences in culture tastes between high socioeconomic and low socioeconomic individuals (Pampel, 2006). Thus, we hypothesize that persons of lower socioeconomic status will be less likely to perceive smoker-related stigma than individuals of higher socioeconomic status.

We define social norms as rules or standards that are understood by members of a group, and that guide and/or constrain social behavior even without the force of law. Stigma theorists point to the centrality of social norms to stigma formation processes. For example, Goffman (1963) argues that stigmatization is a general feature of any society because deviations from social norms are unavoidable and pervasive. Others write that stigmatization is a feature of all societies to extract conformity with social norms, which is necessary to enforce law and order. According to this view, stigmatization is a consequence for failing to comply with social norms for the purpose of making the deviant person conform and rejoin the group (Braithwaite, 1989) or to clarify for other members of the group the behaviors that are unacceptable and the consequences that will affect those who engage in those behaviors (Erikson, 1966). Stigma can only be used in these ways to increase conformity around behaviors and identities that are believed to be voluntary. Thus, we suspect social norms may be especially pertinent to understanding smoker-related stigma.

The task of thinking about how social norms might generate smoker-related stigma is complex because several different types of normative influences exist and they operate at multiple levels in individual's lives. In this study, we delineate two types of social norms. First, are descriptive norms, or the norms of “is”, which are perceptions of what most people do in a particular situation (Cialdini, Kallgren, & Reno, 1991). Second, are a set of social norms that are based not on what other people do, but on a set of normative beliefs: whether particular referents approve or disapprove of the behavior and how motivated the individual is to comply with each of these referents (Fishbein & Ajzen, 1975). These norms have been referred to as the norms of “ought” or as injunctive norms (Cialdini et al., 1991). Of these two norm types, we suspect injunctive norms will be the most relevant to stigma formation processes because they are explicitly normative and judgmental whereas, descriptive norms are formulated based on observations of how often group norms are violated.

The relationship between social norms and smoker-related stigma is further complicated by the fact that individuals are engaged in multiple social groups. Within each group, individuals are likely to encounter both injunctive and descriptive normative influences. Membership in some groups will undoubtedly be more important to individuals than membership in other groups. For example, adults will likely value the opinions of their family and friends more than they value the views of their neighbors although this may not always be the case. Thus, we hypothesize that individual's perceptions of injunctive norms operating at the family and peer level will have a more powerful influence on smoker-related stigma than injunctive norms perceived at the neighborhood level.

We test the following hypotheses across our five theoretical domains in a sample of current and former smokers: (1) individual attributions of responsibility for smoking as well as genetic attributions are positively related to smoker-related stigma whereas, social attributions of responsibility for smoking are negatively related to smoker-related stigma; (2) the fear that smoking poses a health threat to children is positively associated with smoker-related stigma; (3) prior experiences of discrimination and greater exposure to smoke free air laws are positively related to smoker-related stigma; (4) education and income are positively related to smoker-related stigma.; and (5) injunctive norms operating at the family and peer level are more strongly associated with smoker-related stigma than injunctive norms operating at the neighborhood level, and injunctive norms operating at both the family/peer level and the neighborhood levels are more strongly associated with smoker-related stigma than descriptive norms operating at either of these levels.

Section snippets

Study design and data collection

This study was based on survey questions administered as part of the New York Social Environment Study (NYSES). The NYSES was a cross-sectional random digit dial telephone survey of 4000 New York City residents aged 18 years or older conducted between June and December 2005 and was run out of the University of Michigan. It was designed to assess the relationship between neighborhood characteristics and drug use behavior (including tobacco, alcohol and illicit drug use). Interviews were

Results

Fig. 1 shows the prevalence of perceived stigma among current and former smokers who quit since January 2002. 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

Discussion

Using data from a general population survey of New York City residents, we showed that current and former smokers who quit since January 2002 perceive substantial stigma and identified several factors that potentially contribute to this stigma. We found that (a) perceptions of individual attributions for smoking behavior, (b) fear that second hand smoke harms children, (c) structural forms of discrimination perpetrated against smokers, (d) low levels of education, and (e) social norms

Conclusion

Many of the sources of smoker-related stigma identified in this study are malleable. The tobacco control community should address the role of stigmatization in the epidemic and decide if it is something it wants to promote or discourage. A potential benefit of smoker-related stigma is that it may lead people to quit (or dissuade people from taking up smoking to begin with) (Stuber, Galea, & Link, submitted for publication) making it important to undertake studies such as this one, which seek to

References (43)

  • R.B. Cialdini et al.

    A focus theory of normative conduct

    Advances in Experimental Social Psychology

    (1991)
  • Ajzen et al.

    Attitudinal and normative variables as predictors of specific behaviors

    Journal of Personality and Social Psychology

    (1973)
  • American Lung Association. (2007). State laws restricting smoking....
  • B. Alamar et al.

    Effect of increased social unacceptability of cigarette smoking on reduction in cigarette consumption

    American Journal of Public Health

    (2006)
  • American Civil Liberties Union

    Introduction to lifestyle discrimination in the workplace

  • K.A. Bainson et al.

    Dimensions and processes of stigmatization in leprosy

    Leprosy Review

    (1998)
  • E.M. Barbeau et al.

    Working class matters: socioeconomic disadvantage, race/ethnicity, gender and smoking in NHIS 2000

    American Journal of Public Health

    (2004)
  • A. Beveridge

    Segregation

    Gotham Gazette: New York City News and Policy

    (2002)
  • J. Braithwaite

    Crime, shame and reintegration

    (1989)
  • A.M. Brandt

    Blow some smoke my way: passive smoking, risk and American culture

  • R.C. Brownson et al.

    Environmental tobacco smoke: health effects and policies reduce exposure

    Annual Review of Public Health

    (1997)
  • Centers for Disease Control

    Cigarette smoking among adults

    Morbidity and Mortality Weekly Report

    (2004)
  • A.L. Comrey et al.

    A first course in factor analysis

    (1992)
  • P. Corrigan et al.

    An attribution model of public discrimination towards persons with mental illness

    Journal of Health and Social Behavior

    (2003)
  • P.W. Corrigan

    Mental health stigma as social attribution: implications for research methods and attitude change

    Clinical Psychology: Science and Practice

    (2000)
  • K.T. Erikson

    Wayward Puritans: A study in the sociology of deviance

    (1966)
  • L.G. Escobedo et al.

    Smoking prevalence in US birth cohorts: the influence of gender and education

    American Journal of Public Health

    (1996)
  • C.M. Fichtenberg et al.

    Effect of smoke-free workplaces on smoking behavior: systematic review

    British Medical Journal

    (2002)
  • M. Fishbein et al.

    Belief, attitude, intention and behavior: An introduction to theory and research

    (1975)
  • Frieden, T., Mostashari, F., Kerker, B., Miller, N., Hajat, A., & Frankel, M. (2005). Adult tobacco use levels after...
  • S. Galea et al.

    Trends in probable posttraumatic stress disorder in New York City after the September 11 terrorist attacks

    American Journal of Epidemiology

    (2003)
  • Cited by (0)

    View full text