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Introduction
Described as ‘unwritten rules’,1 social norms affect how we interact with others, define which practices we regard as acceptable and serve as heuristics that simplify our decision-making. Norms evolve as shared practices, then become embedded within social groups; once established, they shape and reinforce perceptions of commonly practised behaviours (ie, descriptive norms) that attract social approval or disapproval (ie, injunctive norms).2 Because normative practices may define social group membership and serve as markers of identity and belonging, they become self-enforcing and help to attract new members.3–5
Environments play a critical role in enabling and supporting practices, and thus in creating and embedding social norms. For example, dispensing cigarettes to soldiers and providing ashtrays in public areas signalled smoking’s acceptability, reinforced its normativity within specific settings and helped entrench it as a social practice.6–8 However, environments may also discourage and extinguish social practices. More recently, smoke-free signage has declared that smoking is not acceptable within designated settings,9 10 while removal of large in-store tobacco displays sharply differentiated tobacco from normal consumer goods.11 12
Lopez et al’s four-phase model of the smoking epidemic describes how social norms changed as smoking practices diffused and after knowledge of smoking’s harms increased.13 During the innovation and establishment phase, smoking’s social acceptance increased, followed by rapidly increasing prevalence as new population groups adopted smoking.7 13 Smoking prevalence peaked near the end of the second phase, then declined as knowledge of its harms emerged, prompting regulation, stimulating cessation and reducing its social acceptability.13 Prevalence declined further in the final phase as evidence of smoking’s health risks grew and denormalisation, or loss of social acceptability, increased.13 Western countries, many of which have strong smoke-free policies, provide the clearest illustration of these phases, which are more apparent in high-income countries than in low/middle-income countries.14
In this commentary, we draw on Lopez et al’s model to outline how smoking—using commercially produced and supplied tobacco—evolved as a socially normative practice. We then discuss its subsequent relocation outside accepted social boundaries, review smoking denormalisation and its implications, and propose a fifth phase: the endgame phase. We conclude by considering tobacco companies’ rapidly evolving product array and quest for renormalisation, and explore how the industry’s renewed efforts to influence social norms could affect tobacco endgame strategies and people who smoke.
Phase 1: establishment of cigarette smoking as a normative social practice
Like any new practice, cigarette smoking was initially confined to early adopters; cigarettes were relatively expensive because mass production technologies had not evolved and affordability constrained diffusion. Furthermore, social practices featuring smoking needed to evolve and existing practices had to realign to accommodate smoking.7 Early adoption thus occurred primarily among men from higher income groups who had the resources and social capital to model new practices that others observed and subsequently adopted.13 15–17 Through respondent conditioning, smoking came to represent aspirational attributes that differentiated social class, prompted imitation and uptake across traditional social boundaries, and became increasingly normative.7 17–19
Phase 2: rapidly increasing smoking prevalence
During the second phase, three key factors accelerated smoking’s establishment as a socially normative practice.20–22 First, technological innovations allowed industrial-scale production of cigarettes, which simultaneously reduced costs, increased availability,7 and positioned tobacco companies as normal businesses meeting consumer demand and supporting local economies.13 Second, tobacco companies undertook extensive marketing campaigns to target specific population groups.20 23–27 Third, social environments accommodated and validated smoking as an accepted practice.8 28
Among targeted population groups, women received particular attention and tobacco companies positioned smoking as a symbol of emancipation that could disrupt entrenched gender discrimination precluding women from roles outside domestic environments.23 29 Segregation of African American communities enabled tobacco companies to launch an ‘advertising assault’20 on community members and aggressively target menthol brands. Marketing to Lesbian, Gay, Bisexual and Transgender (LGBT) communities framed tobacco companies as civil liberty champions who acknowledged and validated marginalised groups by creating unique brand offerings.24 27 Positioned as symbols of community membership, these brands replaced ostracism with connection and provided a conduit to status and social acceptance.20 24 30
As well as creating differentiated brands, tobacco companies integrated smoking-related paraphernalia into social settings. Ashtrays, complimentary cigarettes, and lighters welcomed and normalised smoking, and staked out spaces as ‘smoking-friendly’.8 New words legitimising smoking emerged28 31; in Australasia ‘smoko’ evolved from a slang term describing morning and afternoon breaks into a word used in workers’ rights legislation.31 Product placement saw tobacco brands and smoking strategically located in movies, and associated with youth role models,32 33 a strategy that increased smoking initiation among young people and helped recruit ‘replacement smokers’.34–36
During this phase, widespread product availability, reduced product costs and sophisticated marketing embedded smoking as a social practice. Brands served as badges of identity,37 language evolved to reinforce smoking’s normativity and prevalence grew rapidly as smoking was carried within social networks.4 What could possibly go wrong?
Phase 3: smoking prevalence declines and the tobacco industry responds
The third phase represents declines in smoking prevalence and social acceptability following smoking’s heyday. These changes responded to research linking smoking with lung cancer, a previously rare disease,38 and were accompanied by growing public anxiety, a plateau and then decline in smoking prevalence, and increasing concerns about the tobacco industry’s behaviour and legitimacy.39 40
Tobacco companies responded to this threat by launching a masterful public relations campaign, the ‘Frank Statement’, which reached more than 40 million Americans. The Frank Statement questioned whether smoking caused lung cancer, reassured people tobacco products were safe and declared tobacco companies saw their ‘interest in public health as a basic responsibility, paramount to every other consideration in [their] business’.41 Yet, despite the pledges outlined, tobacco companies challenged scientific evidence outlining the risks of smoking, questioned health authorities, attacked individual scientists and made a concerted effort to create doubt about research documenting smoking’s serious health effects.42–47
At the same time as undermining public health science, tobacco companies promoted scientific ‘innovations’, including cigarette filters, as risk reduction technologies.48 While research has now shown that filters do not reduce the toxicity of inhaled smoke,49 people who smoked saw filters as harm reduction tools and an alternative to quitting, and quickly began using them.49–51 Tobacco companies capitalised on harm reduction connotations by introducing filter ventilation and deceptively named ‘light’ and ‘mild’ brand variants that reinforced reduced harm misperceptions and maintained smoking’s social acceptability.52–54
Phase 4: denormalisation
The final phase of Lopez et al’s model describes continuing declines in smoking prevalence, expanding knowledge of smoking’s harms and increased smoke-free regulation. As knowledge that industry ‘innovations’ would not deliver public health gains grew, regulators began dismantling the marketing edifice that maintained smoking’s normativity. Policies restricted tobacco promotions and education campaigns increased the public’s knowledge of smoking’s risks. For example, on-pack warnings began featuring graphic depictions of harms caused by smoking,55 56 while fear appeals, the antithesis of consumer marketing, signalled that smoking was not a benign indulgence but a life-threatening activity.57–60
Many countries introduced measures to protect young people from smoking uptake, including minimum purchase age laws61 and excise tax increases.62 Youth-oriented social marketing, such as the American Legacy Foundation’s Truth® campaign also began.41 63–67 The Truth® campaign exposed tobacco companies as manipulative and dishonest, challenged smoking as a symbol of independence68 and successfully positioned smoke-free behaviour as normative.69 70 Known collectively as denormalisation, these measures fundamentally changed smoking’s social status.71 72
Estimates that exposure to secondhand smoke caused hundreds of thousands of premature deaths every year (currently estimated at 1.2 million) increased the urgency of policy measures mandating smoke-free spaces and saw non-smokers’ advocacy groups develop.9 73–76 Despite tobacco companies’ counter-offensives to challenge research findings,77–80 assert smokers’ rights81 82 and promote a ‘considerate smoker’ persona,83 regulators in many countries established and expanded smoke-free areas.75
Yet, while they may not have prevented stronger regulation, tobacco companies nonetheless influenced debate by reframing smoking not as an addiction, but as a ‘habit’, a term that persists today.84 85 This term locates agency within people who smoke and enabled the tobacco industry to present smoking as an ‘informed choice’, made in full knowledge of the risks involved.86 ‘Personal choice’ arguments later created an important defence in product liability suits and reduced public sympathy for plaintiffs by depicting them as victims of their own actions.87–89
By the late 20th century, many countries had begun introducing policies to reduce the impact smoking had on population health; internationally, these concerns culminated in the Framework Convention on Tobacco Control (FCTC).90 Negotiated via the WHO, the FCTC set out a comprehensive policy approach and signalled globally that the tobacco industry, its products and smoking itself had fallen outside the boundaries of acceptability.91 92
Global regulation and continuing exposure of tobacco companies’ duplicity began changing public sentiment,63 92 and growing evidence of smoking’s threat to human, social and economic well-being provided a clear mandate for political action.93–95 For many countries, the question was no longer what regulators would do to protect citizens from smoking, but how far they would go to end the tobacco epidemic.
Phase 5: endgames and social norms
As denormalisation of tobacco companies and their products grew, discussions within the research and advocacy communities began to focus less on controlling the tobacco epidemic and more on ending it.96–99 Although endgame definitions vary,98 the concept implies a shift in attention from individual action to the government leadership needed to restructure tobacco marketplaces and products.97
This important change challenges depictions of smoking as a personal choice, where individuals carry responsibility for health outcomes they could have neither foreseen nor accepted, given the uncertainty created by tobacco companies. Endgames also recognise that tobacco industry initiatives to foster cessation or deter smoking uptake among youth have never privileged public health goals over profit.100 101 Further, this approach understands that commercial and fiduciary imperatives will inevitably lead tobacco companies to impede and oppose any policy that could reduce their profitability. Endgame proponents argue that, as smoked tobacco is an inherently dangerous product, governments should treat it as such and protect their citizens by setting a date at which smoking prevalence falls to minimal levels.97 Several countries, including New Zealand,102 Finland103 and Scotland,104 have now set endgame goals that specify clear outcomes (reductions in smoking prevalence to 5%) and timelines (2025; 2030 and 2034, respectively).
Establishing a timeline to end the smoking pandemic requires measures that will catalyse profound declines in smoking prevalence and go beyond ‘demand-side’ policies, such as restricting tobacco marketing. Although these latter policies have achieved much, particularly given aggressive industry opposition,105 106 they implicitly accept industry claims that smoking is a personal ‘habit’; if smoking is a matter of individual choice, the need for structural changes to tobacco markets is less obvious.107
By contrast, ‘supply-side’ policies, involving systemic changes that restructure tobacco marketplaces, reconsider the design and availability of tobacco products, and envisage a point when these are no longer supplied using a commercial market model.93 97 107 While potential approaches differ in how much they retain or remove free-market attributes,107–109 all focus on measures that will change how tobacco companies operate and the products they may manufacture. Endgame strategies also use growing public recognition that smoked tobacco is not a normal product made by a legitimate industry to propose transformational measures.110
Yet, despite low trust in tobacco companies,111 countries with an endgame goal have been slow to implement supply-side measures,112 113 leading to grave concerns the timelines set will not be met (though New Zealand’s pending Action Plan may yet see the goal realised in that country).114 Limited progress may partly reflect tobacco companies’ success in shaping social norms regarding public health policy. They and other corporates have framed protective measures as ‘nanny state’ interference that compromises personal freedoms, funded neoliberal front groups to repeat these assertions and promoted public distaste for regulation.105 115–117
Tobacco companies have also attempted to reclaim social legitimacy for themselves and their products, a mission started following the Frank Statement’s publication. Denied the ability to integrate their brands into everyday life via sponsorship and other lifestyle marketing, tobacco companies replaced mainstream marketing with targeted corporate social responsibility (CSR) initiatives. CSR presents companies as caring and responsible corporate citizens, provides lobbying opportunities and embeds commercial entities within communities. For example, industry-funded ‘education’ programmes responded to public concern over smoking among young people (though did nothing to decrease the risk of smoking initiation).101 Environmental initiatives fund local clean-up operations to remove tobacco product waste (though do nothing to change the origin of this problem).118 Tobacco companies have also seized opportunities in developing countries to support sustainable tobacco plantations and assist local economies by providing disaster relief or educational resources.119 120
More recently, tobacco companies have positioned themselves as pioneers developing COVID-19 vaccines, or as benefactors providing medical supplies to assist countries struggling to respond to COVID-19.121 122 Although CSR strategies predate endgame dialogue and exist in countries yet to set endgame goals, they illustrate the priority the industry places on social acceptability and its skill in positioning itself as a source of solutions rather than a creator of problems.119
CSR has created doubt that the industry is irredeemable and recent declarations of self-transformation augment this doubt.123–125 Tobacco companies have declared they will eliminate smoked tobacco products, thus implicitly recognising these products will never again be socially acceptable. Nonetheless, their failure to provide a timeline and aggressive promotion of smoked tobacco in countries with less stringent regulation questions these stated intentions.126 127 The industry’s apparent volte-face evokes the Frank Statement rhetoric; they are again presenting themselves as public health allies and are now offering a ‘solution’: reduced-harm products, such as electronic nicotine delivery systems (ENDS) and heated tobacco products (HTPs).
Tobacco companies’ chameleonic capacity for reinvention and audacious belief they may reframe themselves as a solution to the destruction caused by their combustible products presents new and troubling questions. ENDS marketing has made electronic nicotine products symbols of social capital that connect young people and enable them to bridge social boundaries.128–131 Social media platforms, social influencers and music festivals have replaced tobacco product placement in movies and endorsements by film stars.132–135 These promotions are associated with rapid ENDS uptake among never-smoking young people and have led to widespread concerns that ENDS marketing will create new generation dependent on nicotine.136
Corporate strategy documents support these concerns and show growth in non-combustible products has come more from ‘new entrants’ than from switchers.137 Furthermore, rather than trigger switching and then eventual ENDS or HTP cessation, tobacco companies plan to promote long-term ENDS use among current and former smokers and see their products as ‘additive’.138
Renormalisation has seen industry language integrated into common discourse (eg, promotion of ENDS to ‘quit’ rather than ‘switch’, wording that conveniently overlooks the burden of continuing nicotine dependence).139 Philip Morris has framed its IQOS HTP as ‘smoke-free’ to capitalise on the reduced risk profile associated with ENDS,140 despite evidence HTPs may carry similar risks to smoked tobacco and are almost certainly more harmful than ENDS.141 This rhetorical chicanery reinforces claims the industry offers solutions, not problems, enables them to regain political capital and depicts them as legitimate stakeholders in tobacco control policy debates.142–145
The endgame phase has seen the tobacco industry renew its interest in research alliances. Following an undertaking given in the Frank Statement, tobacco companies funded the Tobacco Industry Research Committee, which internal industry documents revealed as a public relations front used to dispute evidence of smoking’s harms.44 146 147 Philip Morris’s Foundation for a Smokefree World (FSFW), of which it remains the sole funder, has also funded ‘research’ centres.148 Yet, scrutiny of the FSFW’s governing documents questions its independence from Philip Morris.149 Furthermore, FSFW ‘research’ centres have focused strongly on ‘harm-reduction’ products while opposing evidence-based policies that would constrain tobacco companies and attacking public health researchers.150 151
Doubt and division, first created half a century ago by the Frank Statement, again threatens to fracture the public health community and create rifts between those who believe the industry may reform and regain social acceptance, and those who do not.152 Philip Morris International (PMI) strategy documents reveal similar ‘divide-and-conquer’ plans. The company aims to amplify the voices of harm reduction proponents, achieve ‘normalisation’ by presenting ‘anti-tobacco opponents’ as having ‘double standards’ and build political goodwill by engaging ‘non-traditional’ third parties, including those from the scientific community.153 Given these tactics, it is not surprising that views on new nicotine products range from the utilitarian, which accepts the promise of overall harm reduction, to the deontological, which rejects interactions with tobacco companies because of their historical duplicity, continued sales of smoked tobacco products and overt targeting of electronic nicotine products to youth.
Industry reinvention strategies bring their framing of smoking as an individual choice into stark relief and raise new questions about how denormalisation (and industry renormalisation) affect people who smoke.154 Depicting these people as having made poor choices they could rectify enables tobacco companies to position themselves as corporate saviours offering a novel ‘solution’. Personal choice narratives, such as PMI’s proposition that people ‘unsmoke’ their world by switching to IQOS, foster tobacco companies’ personae as reformed corporate characters, but invite judgement of people who smoke. That judgement may be internalised and experienced as stigma,155–157 which may compound other disadvantages.158 159 As smoking prevalence falls, people who continue smoking may feel socially excluded or of lesser value; these feelings may entrench their smoking identities and practices, and undermine the self-efficacy needed for successful quit attempts.160–162
To avoid inadvertently reinforcing industry-inspired norms and alienating those who should benefit most from smoke-free goals, endgame strategies should build on, and enable, leadership within communities most harmed by commercial tobacco and at greatest risk of stigma. Leadership from within these communities will provide a broader perspective on tobacco (eg, commercial vs traditional/sacred use) and its effects on health and well-being. Western (medical) perspectives of health have dominated current thinking, focus on biological impacts of tobacco use and risk presenting endgame goals in terms of minimisation. Because Indigenous people’s experiences of commercial tobacco occurred via colonisation, Western perspectives often overlook the impacts of tobacco use on their social, economic and physical health and well-being. Indigenous leaders, who responded to the havoc commercial tobacco products caused to their communities by proposing endgame solutions, may be well placed to reclaim smoke-free norms and guide the return to traditional smoke-free practices.163 Enabling Indigenous leaders to restore traditional practices requires the endgame phase to prioritise equity, develop partnership approaches and encourage community-led initiatives.
Conclusion
Tobacco companies manipulated social norms to establish smoking as a socially accepted practice and encourage uptake among all population groups. As knowledge of smoking’s addictiveness and harms became incontrovertible, smoking prevalence plateaued then decreased. Smoking as a practice, and tobacco companies as corporate actors, lost status and legitimacy; these changes have protected young people from smoking uptake and triggered quitting among those who smoked. However, tobacco companies have opposed regulation that reinforces their loss of social acceptability and fought hard to regain political influence, community trust and goodwill.
Denormalisation has stimulated new thinking about tobacco endgames that would bring fundamental changes to tobacco markets and products, and shift responses from people who smoke to tobacco companies. However, tobacco companies’ quest for renormalisation, elaborate CSR initiatives, self-proclaimed transformations, product ‘innovations’ and efforts to undermine a once united public health sector raise new and serious questions. Tobacco endgames can be realised, though history suggests governments, not industry renormalisation, will achieve these goals. It is thus crucial that regulators resist industry blandishments, recognise that only they can unsmoke the world and introduce powerful measures to ensure the endgame phase is indeed the final phase of the smoking epidemic.
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Acknowledgments
The authors thank Emeritus Professor Phil Gendall for pithy comments on the penultimate version of the manuscript.
References
Footnotes
Contributors JH conceptualised and planned the manuscript; RE and AW commented on the manuscript plan. JH wrote and developed the manuscript; RE and AW commented on an advanced draft. JH undertook the revisions. All authors have approved the final manuscript.
Funding All authors are funded by the University of Otago, New Zealand.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.