Background: In nations with histories of declining smoking prevalence and comprehensive tobacco control policies, smoking-positive cultures have been severely eroded. Smoking, smokers and the tobacco industry are today routinely depicted in everyday discourse and media representations in a variety of overwhelmingly negative ways. Several authors have invoked Erving Goffman’s notions of stigmatisation to describe the process and impact of this radical transformation, which importantly includes motivating smoking cessation. Efforts to describe nations’ progress toward comprehensive tobacco control have hitherto taken little account of the role of cultural change to the meaning of smoking and the many ways in which it has become denormalised.
Methods: This paper identifies a diversity of generally undocumented yet pervasive markers of the “spoiled identity” of smoking, smokers and the tobacco industry, illustrated with examples from Australia, a nation with advanced tobacco control.
Results: We caution about some important negative consequences arising from the stigmatisation of smokers.
Conclusions: We recommend that schemes rating the comprehensiveness of national tobacco control should be supplemented by documentation of markers of this denormalisation.
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Tobacco control scholarship has given considerable attention to cultural, interpersonal and tobacco industry factors which promote smoking, but relatively little attention to documenting the widespread erosion of social tolerance of smoking which has occurred over the past 40 years in nations with advanced tobacco control policies. These decades have seen major changes in how smoking and smokers are perceived, where smoking can occur, and to the reputation of the tobacco industry with the community and governments. Restrictions on where smoking is permitted in public places have increased markedly, now applying even in some outdoor settings. Throughout this period, the tobacco industry has continued efforts to position tobacco as an unexceptional item of commerce, and its standing as an entirely legitimate, responsible business selling “legal” products. Publicity about political associations with the tobacco industry has today become a kind of reputational “mark of Cain”.
Smoking prevalence has been in almost continual decline in Australia for over 45 years. In the early 1960s, nearly 60% of men and nearly one in three women smoked.1 Today, 13.9% of New South Wales adults smoke daily, with another 3.8% smoking less often.2 While health concerns have been the principal factor driving this decline, smoking has also become increasingly socially unacceptable. A prescient British American Tobacco memorandum from 1976 forecast: “It seems likely that smoking will become increasingly socially unacceptable … as it was in the 1860s. Men had to indulge in the practice out of doors or else … sneak away into the kitchen after the servants had gone to bed and puff up the chimney”.3 By 1984, a Philip Morris official named the changing face of smoking as his industry’s major concern: “… the single most important issue facing our industry is the erosion of the social acceptability of smoking … Today it is probably true to state that even a majority of smokers feel that theirs is an undesirable habit”.4 The tobacco industry has long recognised the power of smoking restrictions to denormalise smoking and reduce consumption.5 Industry plans to thwart smoke-free policy reform stress that “the final objective is to make or keep smoking socially acceptable”.6
BEYOND SPECIFIC INTERVENTIONS
Analysts of the decline of smoking typically privilege the role of particular policy changes and specific interventions in accounts of why smoking is declining in many nations. This is because of evaluation imperatives, where those commissioning interventions understandably wish to assess their impact. However, understanding smoking cessation and why many never start is ill-served by researching only the role of discrete “official” interventions and policies.7 Complete accounts need to also consider the synergistic influence across time of many formal interventions as well as a myriad of “uncounted” cultural influences on the way that smoking is talked about in news and entertainment media, in everyday conversation and on the internet. While particular proximal interventions such as health promotion campaigns or the availability of pharmacological aids may precipitate cessation, distal cultural and environmental factors can be essential in priming communities to be receptive to particular interventions.8 Calls have been made for researchers to consider a far wider range of influential “inputs” into how smoking is changing9 and to “bring the background (of ubiquitous cultural facets of anti-smoking influences) into the foreground”10 of explanations of why smoking is declining. Greater attention to the dynamics of the wide diversity of generally undocumented yet pervasive markers of negative public sentiment about smoking could enrich such explanations.
The term “denormalisation” has gained recent currency as a way of summarising how the tobacco industry has become anything but an unremarkable and normal industry. Ashley and Cohen listed eight facets of tobacco industry denormalisation.11 In the Canadian tobacco control context, the term is used particularly refer to “activities undertaken specifically to reposition tobacco products and the tobacco industry consistent with the addictive and hazardous nature of tobacco products, the health, social and economic burden resulting from the use of tobacco, and the practices undertaken by the industry to promote its products and create social goodwill toward the industry”.12
However, internationally, the term is also used to encompass efforts challenging notions that smoking ought to be regarded as routine or normal, particularly in public settings.13 Hammond et al state that “social denormalisation” strategies seek “to change the broad social norms around using tobacco—to push tobacco use out of the charmed circle of normal, desirable practice to being an abnormal practice”.14
Several authors15–17 have suggested that Erving Goffman’s18 classic analysis of stigma and its resultant “spoiled identity” is consonant with how the meaning of smoking has changed in societies with widespread tobacco control. Goffman described stigmatisation as the transformation “from a whole and usual person to a tainted, discounted one”, writing that “Stigma is a process by which the reaction of others spoils normal identity”. Writing in 1963 before the first US Surgeon General’s report on smoking was published, Goffman did not list smoking as a stigmatised behaviour but did list “blemishes of individual character” that included addiction and alcoholism.
As smoking becomes increasingly denormalised and communities vocal about their dislike of smoking, there is abundant evidence that smokers internalise this negativity. In nations with advanced tobacco control, smokers have almost universal regret about having commenced smoking.19 After health concerns, the social unacceptability of smoking is nominated by most ex-smokers as their main motivation for quitting.20 Denormalising smoking is also associated with protecting others from second-hand smoke. Among factors that positively predicted having a smoke-free home was “believing smoke free was normative” (high acceptance of denormalising beliefs about smoking).21
Joossens and Raw22 have developed the most elaborated instrument for scoring the comprehensiveness of national tobacco control programs. In their 100-point scale, comprehensive tobacco control is coextensive with the implementation of laws and regulations, interventions and resources to support smoking cessation. Yet among the 58 facets they list, there are no measures of how smoking and the tobacco industry have become denormalised. Their instrument ignores variations in the cultural reception given to smoking and the way that this might infect smokers’ identities and their cultural “accommodation”, nor how the tobacco industry is perceived by the public and policy makers. It gives no account to commonplace observations of readily observable differences between nations on how smoking, smokers and the tobacco industry are regulated and perceived by the dominant culture. Such differences are likely to reflect important predisposing, reinforcing and enabling factors23 of great relevance to any explanation of both political action and inaction and community support for tobacco control.
In this paper, we explore some diverse markers of how smoking, smokers’ identities and the tobacco industry’s public reputation have become “spoiled” over recent years in Australia. Many of these are readily observable—or notable for their absence—but relatively few have been quantified or ever monitored. We believe the diversity of examples we provide will be useful as a starting point for researchers to consider the complementary qualitative benchmarking of a richer range of indicators of how advanced tobacco control manifests itself at the cultural level.
THE SPOILED IDENTITY OF SMOKERS
Smoking is a personal practice often conducted in public, social settings and redolent with diverse cultural meanings. While smoking has always had its detractors, in the past smoking in Australia connoted a seemingly unlimited range of mostly desirable attributes, framing it an enticing behaviour for those seeking to affect a variety of presentations of self, particularly youth developing their public identities. Smoking has been imbued with a wide range of significations, forged in public consciousness through advertising, cinema portrayals and other popular cultural representations and their subsequent reproduction in everyday discourse. Richard Klein’s Cigarettes are sublime24 remains the most comprehensive, if often laudatory, analysis of the polysemic meanings of smoking, which for at least the first 60 years of the 20th century were overwhelmingly positive.
But with the exponential escalation of news about smoking and disease that rose from the 1960s with the publication of two historic reviews of the evidence in the UK25 and the USA,26 the meaning of smoking began to transform radically. Today, around 75% of smokers want to stop.27 With daily adult smoking prevalence at 13.9% in New South Wales,2 only 3.5% of adults therefore smoke and want to continue. In most communities in Australia, smoking is evolving into a remarkable activity, and the remarks about it are nearly all negative.
Smoking by Australian teenagers has also fallen to unprecedented levels, with only 6.2% of 17 year olds in Western Australia having smoked more than 100 cigarettes.28 This fall has occurred in the absence of any significant mass reach anti-smoking program targeted at youth,29 suggesting that the movement away from smoking by youth has been stimulated by factors far wider than ostensibly “youth” oriented interventions. Increasingly from the early 1980s onwards, mass reach health campaign advertising in Australia has colonised public perceptions of smoking by showing often unforgettable images of blackened lungs, amputated limbs and bedridden, regretful smokers surrounded by grieving families.30 Today, it is rare to find a magazine item or television program dealing with health improvement that does not condemn smoking.
This relentless tide of bad news about smoking has carried numerous subtexts that have compounded smokers’ spoiled identities, which we highlight below.
Smokers as malodourous
Smoking has long been popularly described as a “filthy habit”. Smoking detritus such as overflowing ashtrays, discarded tar-stained butts and the smell of rooms previously occupied by smokers have all come to connote distinct unpleasantness. Hotels commonly declare whole floors smoke free and give notice that a cleaning fee will be added to the bill if smoking occurs. Many holiday guesthouses advertise that guests must not smoke indoors. Popular anti-smoking slogans in the early 1980s said “Kiss a non-smoker. Enjoy [or taste] the difference”31 and “Kissing a smoker is like licking an ashtray”. Advertising appeals used to sell air fresheners, oral hygiene products and chewing gum often refer to overcoming the smell of smoking. Google searching of various expressions for malodour combined with smoking return many examples, such as 716 000 hits for “smoking [and] bad breath” and 384 000 for “smoking [and] halitosis”.
Smokers as litterers
High profile educational and clean-up anti-littering campaigns routinely highlight cigarette butts and packs as a major component of total litter.32 Australia’s 2.9 million smokers consume an average of 6200 annual cigarettes33 with many of these 17.98 billion butts discarded as litter. Several local governments have banned smoking on beaches, citing litter concerns. In bushfire seasons, outraged callers to radio stations describe witnessing smokers tossing lighted butts from cars into roadside bush litter. Billboard campaigns have shown photographs of charred wildlife killed by cigarette caused fires.34 Smokers are thereby framed as mindless, even criminal antisocial polluters, selfishly discarding their waste, seemingly indifferent to the—sometimes serious—consequences of their actions. In 2002, the New South Wales Premier urged the public to report butt littering from cars “if you observe someone tossing a cigarette butt from a car, do not ring the Environmental Protection Authority (EPA) to make a complaint about littering, ring Crime Stoppers because we regard it as a criminal offence”.35
Smokers as selfish and thoughtless
Smoke-free laws were introduced because of widespread recognition that promoting courtesy and consideration to smokers was often futile in preventing smoking near others.36 When smoking was allowed in restaurants, many witnessed smokers’ indifference to the effect of their smoking on others and occasional aggression when asked to be more considerate. Before the law required smoking to occur outside, many smokers did not refrain from smoking around others, despite extensive health promotion efforts about the harms of second-hand smoke. Smokers were long presumed to be indifferent to their own health, but smoking also became a much-discussed symbol of indifference to others.
Smokers as unattractive and undesirable housemates
Those advertising on dating websites overwhelmingly specify that they are looking for non-smokers.37 In 1992, shared rental accommodation advertisements listed non-smoking as a requirement more than any other attribute.38 Today Australia’s largest internet flatmate finding site, Flatmate Finders (http://www.flatmatefinders.com.au), requires three mandatory descriptors: sex, age range and smoking status. As of 9 April 2007, table 1 shows that while the smoking status of advertisers mirrored the non-smoking prevalence in the community, a negligible number of advertisers named themselves as either wanting accommodation where they could smoke indoors or willing to accept indoor smokers.
Smokers as undereducated and a social underclass
News reports on declining smoking rates often note wide socioeconomic and educational differentials: smoking is increasingly a badge of unemployment, low socioeconomic status and low educational attainment.39 Those aspiring to upwardly mobile socioeconomic status would be unlikely to see smoking as a good “fit” with their ambitions.
Smokers as addicts
94.1% of Australian smokers agree that they are addicted to nicotine.40 Large budget advertising for nicotine replacement products, also seen by non-smokers, typically address their audiences as people repeatedly struggling against the bonds of addiction, and use language redolent with clinical accounts of narcotic use. Nicotine replacement nasal sprays look like apparatus normally used as decongestants and inhalers like asthmatic puffers. Their relative unpopularity compared to patches and gum perhaps suggests that few smokers relish displaying their attempts at quitting to others. Smoking has become increasingly medicalised as a condition framed as needing treatment and causing biochemical changes to neuroreceptors. News reports of developments with vaccines and nicotine antagonists further position smokers as people somehow out of volitional control, needing medication.
Smokers as excessive users of public health services
The cost of smokers’ excess health care use is regularly the subject of news reports following the release of economic reports.41 Recent public debate about whether smokers should be given lower priority than non-smokers in surgical waiting lists or even denied elective surgery paid for by the public health system42 have drawn on implications that smokers are somehow unwilling to assist in improving their own prognosis. Those trying to counter such harsh accounts tend to frame smokers as victims of addiction, undeserving of such opprobrium. Either way, the image of sick, helpless smokers is unflattering.
Smokers as employer liabilities
Smokers are absent from work more than non-smokers.43 For years, smokers have been a feature of urban landscapes, seen taking repeated smoking breaks outside workplaces. This has caused resentment among many non-smokers who are not accorded similar breaks. An online poll conducted by a television station in 2005 asking “Should smokers work longer hours to make up for cigarette breaks?” attracted 93 820 votes, with 70% agreeing (as of 17 June 2005 at http://www.ninemsm.com.au). While many smokers do not take excess sick leave or work breaks, a nascent debate is slowly fomenting about whether employers might be legally and morally justified in refusing to hire smokers44 because of their excess absence from work. Some childminding and nanny employment agencies appear to be already exercising discrimination in this regard (for example, http://www.findababysitter.com.au).
RESTRICTIONS ON SMOKING
Before 1987 when workplace smoking bans first commenced, nearly all smokers smoked uninterrupted in workplaces and, with few exceptions, wherever they went. Today, all offices, shops, indoor shopping malls, all forms of public transport, restaurants, bars and major outdoor stadia are smoke free in Australia. Outdoor workplaces, including building sites, have also started to be declared smoke free.
Smokers are now routinely “exiled” from others, obliged to smoke in often unpleasant surroundings such as parking lots, city alleyways and the delivery entrances to buildings, sometimes in inclement weather. When among large crowds spending long hours at sporting events in stadia, indoor entertainment and other mass gatherings, one can reflect that no one in these vast acreages of humanity is smoking. Smokers must now retire to a fenced off “cage” at Melbourne’s Telstra Dome sports arena.45 Smokers know they have been required to move away from others because most people do not want to be exposed to their smoke. Smoking is no longer a convivial and integral part of everyday life. In large part, it has become an activity largely removed from routine human interaction.
Smoking at leisure
Smoking was banned inside restaurants and cafes in most Australian states in 2000 and in bars by July 2007. Today, while others enjoy food, wine and conversation in a restaurant, many smokers are thinking about how they might quietly get outside to stand in the street to relieve their discomfort from lack of nicotine. Here they will often increase their puff frequency to nearly double the normal rate.46 Even outdoor concerts and music festivals are now starting to make stage announcements that smoking is confined to special areas away from where people are eating or crowded listening to music (for example, Womadelaide; http://www.womadelaide.com.au/info/index.html).
At the start of every airline flight to, from and within Australia passengers are warned via onboard announcements that smoking is banned in-flight and, evoking memories of warnings given to schoolchildren about toilet-block smoking, an added warning is given that they must not smoke in aircraft toilets. In 2004/2005, 54.93 million passengers heard these announcements in Australia.47 When each flight ends, it is then seen as necessary to remind smokers that they cannot light up until they get outside the airport buildings. Again, the subtext of the message is plain: here are desperate addicts counting the seconds until they can smoke.
Smoking rooms at airports
In the 1990s, the tobacco industry lobbied for the construction of dedicated smokers’ rooms inside airports. In these, smokers congregated in small glassed-in rooms, typically thick with smoke and overflowing ashtrays, while other passengers moved past observing their segregation. Inside, smokers have time to reflect yet again on their “otherness”, and why they feel compelled to subject themselves to such indignity. “Fishbowl” smoking rooms may function as living anti-smoking “billboards”. Many sitting in them must occasionally pause to reflect: “I’m sitting in this awful room because I smoke”. Smokers sometimes protest that they are made to feel like social “lepers”. In early 2007, these uninviting rooms were quietly removed from Australian airports with no fanfare or public objection. Sydney airport’s policy today is to “accommodate the needs of smokers by providing designated smoking areas that are located outside” (http://www.sydneyairport.com.au/SACL/Terminal+Information/T1+International+Terminal/Services+and+Amenities/default.htm).
Smoking in homes
Until the mid-1980s, it would seldom occur to ask a smoker visiting one’s home to step outside to smoke. Yet in 2006, 43% of Australian households with smokers totally ban smoking indoors.48 Today, it would be almost inconceivable that a smoker would smoke inside another’s house unless explicitly invited to do so. For nearly half of smokers, smoking has become something that has been exiled from even the most private of spaces, the home. There are no other “ordinary” domestic behaviours where a person is asked by his or her own family to go outside to engage in that behaviour.
In 2006, the New South Wales Consumer, Trader and Tenancy Tribunal upheld a case brought by occupants of an apartment against their smoking neighbours, requiring them to stop smoking in their adjacent apartment because of smoke drift.49 This precedent will undoubtedly precipitate other such actions and give license to rental managers to advise tenants that smoking is banned in rental apartments.
In Australia and a growing number of nations (a complete list can be found at http://www.smoke-free.ca/warnings/default.htm), smokers today must take their cigarettes out of a pack that might show a colour photo of a gangrenous foot, a disfiguring oral cancer, a blackened lung or (in Canada, Brazil and Thailand) a suggestion that the man with the pack may have erectile dysfunction problems. Cigarette packs were once elegant accoutrements of style, but today their designer boxes are desecrated with images that have tested strongly in focus group to repulse and unsettle large proportions of smokers. People are used to seeing strong health warnings on household goods such as drain cleaning chemicals, rodent poison and garden pesticides. But even these do not carry pictures showing damaged alimentary tract organs after ingesting such products. Tobacco products are thus positioned as exceptionally dangerous.
The four car manufacturers operating in Australia no longer offer cigarette lighters or ashtrays as standard features for most models. A power source for electronic equipment has replaced the standard lighter. Both GM Holden Ltd and the Ford Motor Company of Australia Ltd charge a fee for installing a “smoker’s kit” option on newly purchased vehicles. Imported Peugeot, Volvo and Volkswagens are sold without lighters and ashtrays. All major hire car companies offer non-smoking cars.
All major life insurance companies have long offered significant premium reductions to non-smokers. Similar discounts are not offered to people with normal weight or indeed for any other risk factor. Non-smokers are even able to find preferential car and home insurance rates in recognition of the reduced risk of insurance claims. While smokers may be sceptical about health risk claims voiced by health officials, the same claims made by insurance companies with access to actuarial data is likely to carry different weight, again reinforcing smokers’ sense of difference.
Spoiled identity of the tobacco industry
The tobacco industry in Australia has evolved from a time when its senior members were regularly knighted as respected captains of industry, into a pariah industry routinely vilified in the media.50 Legal analysis arguing that industry officials should be charged with criminal offences51 has attracted media coverage. Repeated, commonplace, unfavourable framing of the tobacco industry seems likely to be associated with the community’s ranking of tobacco industry representatives’ trustworthiness as lower than that of used car salesmen, traditionally the populist low-water mark of ethical business conduct.52 53 Australians have stronger anti-tobacco industry beliefs than residents of the US, Canada or the UK.14 The tobacco industry has become a routine shorthand benchmark for describing all manner of corporate malfeasance. A Google search on “like the tobacco industry” returns 13 300 hits, with most being similes for a range of negative values. Illustrative examples are shown in box 1.
Illustrative examples of unfavourable depiction of the tobacco industry
“Critics claim the cell phone industry, just like the tobacco industry (Big Tobacco), seems determined to prevent and deny any suggestion that its products...” (http://www.mercola.com/2005/mar/26/cell_phones.htm)
“So-called global warming sceptics are referred to as “in denial just like the tobacco industry” (http://www.theage.com.au/news/business/cool-heads-needed-on-global-warming/2007/01/18/1169095910210.html)
“… to find the results that will protect business interests, just like the tobacco industry scientists who said cigarettes don’t cause cancer” (http://www.aei.org/publications/pubID.8657/pub_detail.asp)
“.. industries systematically concealed data and lied to regulators about the health effects of automobile emissions - just like the tobacco industry” (http://www.longwoods.com/product.php?productid = 18697&cat = 468&page = 1)
“So now you’re looking at an industry, just like the tobacco industry, that’s dependent on people with behavioral problems” (http://www.mac10.umc.pitt.edu/u/FMPro?-db = ustory&-lay = a&-format = d.html&storyid = 7301&-Find)
“Just like the tobacco industry did with Joe Camel, marketing cigarettes to kids, the video game industry is marketing sex and violence and morally bankrupt” (http://www.illinois.gov/PressReleases/PressReleasesListShow.cfm?RecNum = 3590)
Novels and movies
The tobacco industry has been the subject of at least one best-selling novel, John Grisham’s The Runaway Jury, and two movies (The Insider, the 50th most watched movie in 2000 according to http://www.afc.gov.au/gtp/wctop00.html, and the satire, Thank you for Smoking). In a rare exploration of the impact of a movie on public attitudes, viewing The Insider was shown to increase already negative attitudes to the tobacco industry.54
Courier and credit card company boycotts
At least three courier companies, FedEx, DHL and UPS have policies refusing to deliver tobacco products ordered via the internet.55–57 In March 2005, major credit card companies agreed to immediately cease to process internet sales of cigarettes.58
A total of 17 Australian universities have explicit policies preventing their staff from accepting support of any kind from tobacco companies (http://jech.bmj.com/cgi/data/58/5/361/DC1/3). While there are undoubtedly implicit, unwritten policies that would prevent legal entities such as pornographers, representatives of despotic nations or mercenary recruitment companies from sponsoring university research, explicit policies only exist preventing tobacco company associations. At least two Australian universities (Sydney and Western Sydney) do not allow tobacco companies to participate in campus graduate recruitment fairs. Again, no other industry is excluded like this. In 2003, a former state political premier who, after leaving politics, chaired British American Tobacco Australia, resigned from a university advisory post after a vote condemning his appointment was carried by the university’s governing senate.59
Ethical investment firms have proliferated in Australia in recent years, and the tobacco industry is invariably listed in such firms’ prospectuses as an obvious example of the sort of industry an investor with ethical concerns would not wish to support.
Corporate social responsibility rejections
The tobacco industry has embraced the burgeoning corporate social responsibility (CSR) movement in an attempt to “rebirth” its reputation.60 However, in Australia, an attempt by a tobacco company to share the program of one CSR conference saw other industry participants threaten to withdraw if the tobacco company participated,61 again an unprecedented development.
NEGATIVE CONSEQUENCES OF DENORMALISATION?
While there is abundant empirical support for the proposition that the denormalisation of smoking and the tobacco industry has been associated with large reductions in smoking, increases in cessation and the political marginalisation of the tobacco industry, it is equally important to consider and where possible to redress any harms that have been associated with this trend. Questions arising here include: Are smokers less likely to seek medical help due to public debates around whether they “deserve” medical treatments?62 Will they feel ashamed when doing so, adding to their stress and perhaps prognosis63 Are smokers unreasonably discriminated against in the workplace, even when they do not smoke indoors and put others at risk? (In 2005, the World Health Organisation announced that it would no longer hire smokers in any part of the organisation (http://www.who.int/employment/recruitment/en/).) Are sick smokers seeking legal redress unjustly vilified in popular consciousness as people entirely to blame for having taken up smoking as children and being unable to quit because of addiction?64 Do smoking prevalence surveys systematically under-report smoking because of smoker shame?65
Bayer and Stuber conclude that a utilitarian calculus has to be applied to the resolution of such concerns, noting that “policies and cultural standards that result in isolation and severe embarrassment are different from those that cause discomfort … Acts that seek to limit the contexts in which smoking is permitted are different from those that restrict the right to work, to access health or life insurance, or to reside in communities of one’s choice”.15
What this paper adds
Traditional measures of the denormalisation of smoking have concentrated on the proliferation of restrictions on smoking and the tobacco industry’s reduced ability to promote its products. However, a far wider range of markers of denormalisation exist, which are seldom captured in comparative overviews of comprehensive tobacco control. Nations with robust tobacco control cultures have seen extensive stigmatisation of smoking and erosion of tobacco industry standing in popular and political discourse. This paper describes a diverse range of markers of this denormalisation and urges that progress reports on national tobacco control complement “score card” accounts of progress be complemented with qualitative data on the diverse ways that the positive culture of smoking has been eroded.
The above markers of “spoiled identity” are readily apparent to anyone living in Australia although not subject to any surveillance in the way that orthodox indices of tobacco control are routinely monitored. Their neglect is likely to reflect preoccupation with evaluating state-run interventions and possibly beliefs that such markers are ephemeral rather than potentially powerfully contributory to and reinforcing of tobacco control.
Joossens and Raw’s checklist22 on comprehensive tobacco control comprises objective yes/no and scalable items on policies, laws and programs, while most of the issues that we have described are essentially qualitative. Many appear frequently in public discourse, but our interest is more with the way that they are laden with such obvious negativity. We are not suggesting that the simple addition of a few items on denormalisation to Joossens and Raw’s scale would suffice. Our concern is more to highlight that the completion of such checklists to measure progress in tobacco control needs supplementing with qualitative appraisal of the ways that smoking and the tobacco industry are talked about in societies where smoking has become denormalised. Those concerned with monitoring progress toward comprehensive tobacco control should consider gathering periodic information on the range of markers we have explored and publishing these as a kind of social barometric report on cultural attitudes toward smoking and the tobacco industry. This information could include routine questions in population surveys about smokers’ regret over smoking and self-identification as addicted. Media monitoring studies of discourse about smoking could note the distribution of negative versus positive reportage about smoking and the tobacco industry.66
We have listed and discussed a diverse range of markers of denormalisation that have largely unexplored status as interesting epiphenomena, but which collectively, we would argue combine to repeatedly make the overall cultural proposition that smoking and the industry behind it are decidedly negative. For the individual, an obvious escape from this negativity is to quit smoking, as hundreds of thousands do each year. For governments, this negativity foments a public climate that is highly receptive to tobacco control legislation, polices and programs. We would argue that there is a dynamic, synergistic relationship between formal tobacco control interventions and policies, falling smoking prevalence and the increasing range and growth of the markers we have listed. Arguably, the effect of these markers both stimulate cessation and in turn are themselves amplified by decreasing smoking prevalence as more and more citizens turn away from smoking and revile the tobacco industry’s role in trying to promote it.
The authors thank those on the Australian TCN (Tobacco Control Network) listserver who contributed examples of denormalisation.
Funding: This research was supported by NHMRC grant #401558
Competing interests: None declared.