AMA Journal of Ethics. May 2017, Volume 19, Number 5: 475-485.
Medicine and Society
Decreasing Smoking but Increasing Stigma? Anti-tobacco Campaigns, Public Health, and Cancer Care
The stigma of lung cancer must be addressed by both clinicians and hard-hitting anti-tobacco public health campaigns.
Kristen E. Riley, PhD, Michael R. Ulrich, JD, MPH, Heidi A. Hamann, PhD, and Jamie S. Ostroff, PhD
Tobacco use remains the leading cause of preventable death in the United States, with cigarette smoking killing more than 480,000 Americans every year . An estimated 41,000 of these deaths among adults are attributable to secondhand smoke exposure . Every day in the US more than 3,800 youths under the age of 18 smoke their first cigarette; an estimated 26 percent of these will become adult smokers .
Given the well-established health consequences of smoking, the public health community has established and maintained a comprehensive tobacco control effort, including restrictions on smoking in worksites and other public places, increased tobacco taxation, increased access to evidence-based tobacco treatment, and public health national media campaigns . Collectively, this comprehensive tobacco control effort represents one of the leading public health success stories. In the 50 years since the 1964 Surgeon General’s report, Smoking and Health, US adult smoking rates have fallen from 43 percent to 18 percent .
Although what we’ll call “hard-hitting” anti-tobacco public health campaigns—those with fear-arousing messages—have been shown to be the most effective type of anti-tobacco mass-reach health communication interventions, they might have the unintended consequence of stigmatizing those with smoking-related illnesses [5, 6]. In this paper, we explore the ethical dilemma whereby these campaigns are seen as helpful for public health in promoting smoking prevention and cessation but also potentially harmful for persons suffering from tobacco-related illnesses, including lung cancer. We discuss types of stigma and ethical implications, drawing upon concepts such as respect for persons. We then make recommendations for public health campaigns to incorporate counter-stigmatizing themes and for health care professionals to use empathic communication to mitigate the effects of stigma on patients with tobacco-related diseases. Finally, we provide direction for future research.
Hard-Hitting Anti-tobacco Public Health Campaigns Are Effective in Reducing Smoking Prevalence
Hard-hitting media anti-smoking campaigns often focus on both raising awareness about the health consequences of smoking and denormalizing smoking behavior, thereby motivating prevention among the general public and motivating smokers specifically toward cessation [7-9]. The term “hard-hitting” has been used to describe ad campaigns that are uncompromisingly direct, often with strong fear-arousing messages and personal stories about negative health consequences of smoking. These types of ads are supported by well-established theories of health behavior change (e.g., the Health Belief Model , the theory of planned behavior [11, 12]) that focus broadly on cognitive, emotional, and social processes (e.g., perceived susceptibility to disease, health beliefs regarding the consequences of behavior change, self-efficacy, and social norms) that predict behavior change.
Hard-hitting ads have been shown to be more effective than humorous or neutral educational communication messages at reducing smoking . Most recently, the Tips From Former Smokers™ campaign , featuring real people suffering from serious medical conditions as a result of smoking and exposure to secondhand smoke, has been credited with an estimated 1.64 million American smokers making a quit attempt; 100,000 of these smokers are expected to maintain smoking abstinence . Public health leaders assert that the hard-hitting ads are justified by the benefits observed in reducing smoking and related health consequences [5, 15-17]. Although some hard-hitting anti-tobacco campaigns (e.g., graphic warnings on cigarette packs) have been challenged by the tobacco industry [18, 19], the Family Smoking Prevention and Tobacco Control Act of 2009 gives the FDA authority to regulate the tobacco industry . Regardless of these legal challenges, hard-hitting anti-tobacco public health campaigns remain best practice for mass-reach public health communications.
Do Hard-Hitting Anti-tobacco Ad Campaigns Contribute to Stigma?
There are several types of stigma that might be experienced by patients diagnosed with lung cancer: (1) anticipated stigma, or the expectation of discrimination, stereotyping, or prejudice; (2) enacted stigma, which involves actually experiencing discrimination, stereotyping, or prejudice; and (3) internalized stigma, which refers to people’s self-endorsing negative feelings and beliefs about themselves . While effective in decreasing smoking rates, hard-hitting anti-tobacco public health campaigns might increase the third kind of stigma. That is, internalization of stigma can result in negative self-appraisal and self-devaluation among persons diagnosed with lung cancer and other tobacco-related diseases [5, 6]. The majority of persons diagnosed with lung cancer report experiencing stigma, often related to guilt, regret, perceived blame, and other negative beliefs about smoking history [16, 22-24].
Stigma is associated with a number of deleterious psychosocial and medical outcomes in lung cancer patients, including delayed diagnoses [25-27], poor quality of life , and poor patient-clinician communication . Although there has been limited investigation of stigma and long-term outcomes, stigma may have clear downstream effects, such as reduced treatment adherence and heightened psychosocial distress [24, 28]. One survey found that physicians were more likely to refer breast cancer patients than lung cancer patients for further therapy , which could be due to lung cancer stigma—the ubiquitous and damaging nature of which is well established [24, 28, 29].
Previous research has additionally pointed to differential rates of stigma experienced by lung cancer patients who used to or who currently smoke and those who have never smoked. Namely, lung cancer patients who have smoked and those who currently smoke report higher levels of stigma than those who have never smoked , although lung cancer patients who have never smoked also report experiencing stigma . Given the epidemiology of lung cancer, health care professionals might assume that a patient’s lung disease is acquired “firsthand” as opposed to “secondhand” or without smoking exposure at all. As stigma is experienced by patients across this continuum of smoking exposures, the salience of this ethical debate is relevant for current, former, and never smokers—all those suffering from illnesses associated with smoking.
An Ethical Dilemma
While recognizing that the public health goals of tobacco prevention and cessation remain paramount, an ethical question arises as to whether these ads should continue to be hard-hitting or whether public health communication messages should be reframed to try to reduce stigma and blame that could be experienced by the 16 million Americans living with smoking-related diseases . Looking at denormalization of smoking through a purely utilitarian lens renders a favorable assessment, as evidenced by a 12 percent drop in the smoking rate of 18- to 29-year-olds in the US from 2005 to 2015 . However, when viewing hard-hitting anti-tobacco public health campaigns as sanctioned social stigmatization in the context of people suffering from nicotine addiction and related medical illnesses, the “benefits” of these anti-tobacco ads should be tempered . Internalized stigma (e.g., self-blame, shame, or guilt) could result in low self-esteem as people question their identity and self-worth. In its extreme form, stigma can be thought to “turn the individual into his own jailor, his own chorus of denunciation” .
Mental health clinicians caring for the psychosocial needs of cancer patients and health care ethicists have questioned whether the public health benefits are worth the “incidental” costs of stigma for individual patients [16, 34, 35]. Some health scientists have labeled anti-tobacco public health campaigns “demoralizing”  and “victim blaming” . Additionally, hard-hitting campaigns could extend lung cancer stigma to any person who suffers from any smoking-related illness, regardless of the patient’s actual smoking history . This “guilt by association” can be especially difficult for those with secondhand or even no prior tobacco exposure who perceive others’ negative attitudes as based on false assumptions about the nature and scope of their disease culpability. Given the current demographics of tobacco use, these campaigns might further stigmatize low-income and other vulnerable populations of smokers, who currently represent the majority of tobacco users . And people who already feel disempowered tend to feel even more resentful, defensive, and demoralized after exposure to anti-tobacco campaigns [17, 36]. As a result, hard-hitting anti-tobacco ads could exacerbate health disparities and discourage access to high-quality health care.
An important ethical question is how much iatrogenic stigma should matter if hard-hitting campaigns are successful in preventing tobacco use and motivating smoking cessation as public health goals. Stigma and associated distress certainly matter at a level of clinicians interacting with individual patients diagnosed with lung cancer or other tobacco-related diseases. How much should an individual’s experience of stigma matter at a macro- and public health level of disease prevention? If the overarching goal is to reduce the negative health effects of tobacco use and smoking, whether the result of firsthand or secondhand use, the potential stigmatizing impact of anti-tobacco ads on those who are already suffering from tobacco-related illnesses such as lung cancer cannot be ignored.
Stigma is not benign and has been shown to be associated with lung cancer patients’ avoidance or delay of seeking medical care , resulting in downstream risk of worsening lung cancer morbidity and mortality. While public health principles often emphasize prevention, stigma does not exclude those populations that prevention efforts have failed to reach. Meanwhile, the ethical principle of respect for persons and appreciating the intrinsic value of each individual requires that those who are suffering from tobacco-related illnesses, such as lung cancer, be treated with equity and justice. Health care professionals taking their ethical obligation of nonmaleficence seriously should certainly be concerned about their roles in whether and how their individual patients experience stigma as a result of their specific actions or communications.
What Should Be Done?
Because anti-tobacco public health campaigns have been effective in reducing population smoking rates, banning hard-hitting ads completely would be shortsighted. Our attempt to raise awareness about the impact of lung cancer stigma is not to suggest that public health campaigns refrain from educating the public about the unquestionable, far-reaching health hazards of smoking. Rather, we offer several recommendations for addressing the iatrogenic consequences of hard-hitting anti-tobacco campaigns.
First, public health campaigns could highlight counter-stigma themes. One such theme is the unscrupulous, predatory nature of big tobacco as an industry. Emphasizing how much money is spent annually by the tobacco industry on tobacco advertising and social marketing has been a compelling theme for prior anti-tobacco campaigns, particularly those targeting prevention of youth smoking [37-39]. The Lung Cancer Alliance’s campaign, “No One Deserves to Die of Lung Cancer,” serves as an excellent example of an effective public health campaign that acknowledges the dangerous nature of cigarette smoking while also emphasizing compassion and a nonjudgmental stance by using the ironic message that certain segments of the population (e.g., cat ladies, hipsters) deserve to die . Ads that provide self-affirming messages (e.g., the value of raising a family or maintaining health) might buffer against defensive processing—dismissal of a health message perceived as personally threatening—because it has been shown that self-affirmation prior to exposure to graphic images on cigarette pack warnings reduces such defensive processing . Recent research shows that gain-framed messages—those that highlight benefits of quitting rather than costs of smoking—might be more effective for smokers who feel helpless and demoralized in their quitting efforts . We also recommend ads that encourage the use of evidence-based smoking behavior change strategies and promote self-efficacy in quitting. Finally, given that lung cancer stigma can intersect with social and structural hierarchies such as power, culture, and privilege , it would seem important for public health campaigns to target all tobacco users, not just ethnic minorities and tobacco users of low socioeconomic status .
Second, health care professionals treating patients with lung cancer can communicate empathically to build patients’ resilience and try to help inoculate them to the stigmatizing effects of anti-tobacco health campaigns [6, 24, 26, 28]. One study found that physicians miss 90 percent of opportunities for demonstrating empathy in lung cancer care . Physicians have noted the challenge of advising their patients to quit smoking while concurrently managing patients’ emotional distress following cancer diagnosis and treatment . Good patient-clinician communication has been associated with lower levels of stigma in the health care setting . Building resilience in lung cancer patients and those with tobacco-related illnesses through empathic responses and problem-focused strategies may mitigate the negative consequences of stigma resulting from hard-hitting anti-tobacco campaigns . We currently are working to develop and evaluate an empathic, nonjudgmental communication skills training module for health care professionals treating patients with lung cancer that focuses on taking a detailed tobacco history, advising current smokers to quit, and making a reliable referral for tobacco treatment services.
Additional research is needed to determine how anti-tobacco campaigns can minimize the internalized stigma of patients living with tobacco-related diseases without compromising the campaigns’ strong public health effectiveness. For example, public health campaigns are often pretested using focus groups; new candidate ads could be assessed for whether and to what extent they generate stigma and unintended consequences such as shame and guilt. To our knowledge, the Tips campaign has not examined whether patients with lung and other tobacco-related conditions experience heightened stigma and regret. We recommend eliciting patient perspectives early in the development of anti-tobacco campaigns. There is much to be learned from other public health campaigns grappling with similar concerns (e.g., risky sexual and drug use behaviors and HIV/AIDS, alcohol and driving, obesity, and sun exposure). The Joint United Nations Programme on HIV/AIDS (UNAIDS) has suggested that negative views of people living with HIV can be attributed largely to stigma and ignorance about the harm of stigma and moral judgment, which is likely germane to those suffering from tobacco-related diseases . Accordingly, the HIV/AIDS public health community has made a concerted effort to examine the impact of stigma and embark on multipronged efforts to counter stigma with educational programs targeting specific vulnerable populations, in addition to addressing the role of health care professionals in exacerbating the effects of stigma .
Overall, hard-hitting anti-tobacco public health campaigns work, although they might also inadvertently increase stigma among lung cancer patients, leading to deleterious downstream psychosocial and medical outcomes for this vulnerable population. Specific recommendations include shifting the focus of public health campaigns away from patient blaming and emphasizing clinician-level empathic communication interventions. Further research and attention are needed to ensure that hard-hitting anti-tobacco campaigns find the “sweet spot” for maximizing tobacco control while minimizing stigma experienced by lung cancer patients and those suffering from tobacco-related illnesses. Researchers, leaders of nonprofit organizations, government, hospital systems, health care professionals, and patient advocates can all be involved and accountable for decreasing stigma directed towards lung cancer patients.
Kristen E. Riley, PhD, is a postdoctoral research fellow at Memorial Sloan Kettering Cancer Center in New York City, where she studies health behavior decision making and tobacco cessation for cancer prevention.
Michael R. Ulrich, JD, MPH, is an assistant professor in the Center for Health Law, Ethics & Human Rights and the Department of Health, Law, and Policy Management at Boston University School of Public Health. He studies public health, ethics, and law.
Heidi A. Hamann, PhD, is an associate professor in the Departments of Psychology and Family and Community Medicine at the University of Arizona in Tucson. Her primary research focuses on psychosocial and behavioral concerns, including stigma of lung cancer patients and survivors.
Jamie S. Ostroff, PhD, is the chief of the behavioral sciences service in the Department of Psychiatry and Behavioral Sciences at Memorial Sloan Kettering Cancer Center and a professor of psychology in the Department of Healthcare Policy and Research at Weill Cornell Medical College, both in New York City. Her cancer prevention and control research focuses on tobacco cessation and stigma experienced by patients with lung cancer.
This work was supported in part through a cancer center support grant (P30CA0087748) from the National Cancer Institute to the Memorial Sloan Kettering Cancer Center, a training grant from the National Cancer Institute (T32CA009461) (KER), the National Cancer Institute (R03CA154016) and the National Lung Cancer Partnership and its North Carolina Chapter (Young Investigator Award, HAH), and the Lung Cancer Research Foundation (JSO). We would like to thank Jack Burkhalter, PhD, Lisa Carter-Harris, PhD, Maureen Rigney, LCSW, and Christine Sheffer, PhD, for their constructive feedback on an earlier version of this paper.
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