"But it just has that sort of feel about it, a leper"--stigma, smoke-free legislation and public health

How do people who smoke perceive a tobacco retail outlet reduction policy in Aotearoa New Zealand? A qualitative analysis

BACKGROUND

Aotearoa New Zealand plans to greatly reduce tobacco retail outlets, which are concentrated in areas of higher deprivation and perpetuate health inequities caused by smoking and borne particularly by Māori. However, we lack in-depth analyses of how this measure could affect people who smoke.

METHODS

We undertook in-depth interviews with 24 adults from two urban areas who smoke. We used a novel interactive mapping approach to examine participants' current retail outlets and their views on a scenario where very few outlets would sell tobacco. To inform policy implementation, we probed participants' anticipated responses and explored the measure's wider implications, including unintended impacts. We used qualitative description to interpret the data.

RESULTS

Most participants anticipated accommodating the changes easily, by using alternative outlets or bulk-purchasing tobacco; however, they felt others would face access problems and increased costs, and greater stress. They thought the policy would spur quit attempts, reduce relapse among people who had quit and protect young people from smoking uptake, and expected more people to switch to alternative nicotine products. However, most foresaw unintended social outcomes, such as increased crime and reduced viability of local businesses.

CONCLUSIONS

Many participants hoped to become smoke-free and thought retail reduction measures would prompt quit attempts and reduce relapse. Adopting a holistic well-being perspective, such as those developed by Māori, could address concerns about unintended adverse outcomes and provide comprehensive support to people who smoke as they adjust to a fundamental change in tobacco availability.

Challenges in legitimizing further measures against smoking in jurisdictions with robust infrastructure for tobacco control: how far can the authorities allow themselves to go?

BACKGROUND

According to a recently published study, approximately half of those who currently smoke in Norway have little or no desire to quit despite a hostile regulatory and socio-cultural climate for smoking. On this background, we discuss some challenges that regulators will face in a further tightening of structural measures to curb smoking.

MAIN BODY

Central to our discussion is the research literature concerned with the concept of state-paternalism in tobacco control-the line between an ethically justified interference with the freedom of those who smoke and an exaggerated infringement disproportionate to the same people's right to live as they choose. In countries with an already advanced infrastructure for tobacco control, this dilemma might become quite intrusive for regulators. We ask that if people, who smoke are aware of and have accepted the risks, are willing to pay the price, smoke exclusively in designated areas, and make decisions uninfluenced by persuasive messages from manufacturers-is a further tightening of anti-smoking measures still legitimate? Strengthening of the infrastructure for tobacco control can be seen as a "help" to people who-due to some sort of "decision failure"-continue to smoke against their own will. However, for those who want to continue smoking for reasons that for them appear rational, such measures may appear unwanted, punitive, and coercive. Is it within the rights of regulators to ignore peoples' self-determination for the sake of their own good? We problematize the "help" argument and discuss the authorities' right to elevate the zero-vision of smoking as universally applicable while at the same time setting up barriers to switching to alternative nicotine products with reduced risk.

CONCLUSION

We recommend that a further intensification of smoking control in countries that already have a well-developed policy in this area requires that regulators start to exploit the opportunity that lies in the ongoing diversification of the recreational nicotine market.

Is the perceived public stigma of smokers associated with value opposites? An exploratory cross-sectional analysis of Norwegian data 2011-2013

Smoker stigma is a likely unintended consequence of tobacco polices aiming to denormalise smoking. Little is known about the dissemination of stigmatising attitudes toward smokers at the population level, including their associations with personal values. Applying a theoretical approach that conceptualises stigma as a cultural (moral and intersubjective) issue, we analyse the spread of perceived public stigma of smokers in Norway and factors predicting agreement with such a perception. Using merged data from the biennial national survey Norwegian Monitor 2011 and 2013 (N = 7,792), we tested whether the tendency to agree with a perceived public stigma of smokers differs by four indexes of value opposites ('puritanism/emancipation,' 'conformity/individuality,' 'tolerance/intolerance,' 'status/anti-status'), controlling for smoking status, SES, and demographics. Descriptive statistics and block-wise logistic regression models were applied. In the total sample, 59.1% agree with the statement that 'most people think less of a person who smokes.' Two of the four indexes of value opposites tested were associated with tendencies to agree with the perceived public stigma of smokers ('puritanism/emancipation' and 'status/anti-status'). Smokers with current plans to quit expressed the highest perceived public stigma, while ex-smokers expressed a higher perceived public stigma than never-smokers. Women, young people and respondents with high SES agree with a public stigma of smokers more than men, older people and respondents with low SES do. The perceived public stigma of smokers is high in Norway and varies to some extent with personal values, but also with socio-demographics and especially smoking status.

Terms tobacco users employ to describe e-cigarette aerosol

BACKGROUND

The scientific term for the substance people inhale and exhale from a vaping device is 'aerosol', but whether the public uses this term is unclear. To inform tobacco control communication efforts, we sought to understand what tobacco users call e-cigarette aerosols.

METHODS

Participants were a national convenience sample of 1628 US adults who used e-cigarettes, cigarettes or both (dual users). In an online survey, conducted in spring 2021, participants described what 'people inhale and exhale when they vape', using an open-ended and then a closed-ended response scale. Participants then evaluated warning statements, randomly assigned to contain the term 'aerosol' or 'vapor' (eg, 'E-cigarette aerosol/vapor contains nicotine, which can lead to seizures').

RESULTS

In open-ended responses, tobacco users most commonly provided the terms 'vapor' (31%) and 'smoke' (23%) but rarely 'aerosol' (<1%). In closed-ended responses, the most commonly endorsed terms were again 'vapor' (57%) and 'smoke' (22%) but again infrequently 'aerosol' (2%). In closed-ended responses, use of the term 'vapor' was more common than other terms among people who were older; white; gay, lesbian or bisexual; college educated; or vape users only (all p<0.05). In the experiment, warnings using the terms 'aerosol' and 'vapor' were equally effective (all p>0.05).

CONCLUSIONS

The public rarely uses the term 'aerosol' to describe e-cigarette output, potentially complicating educational efforts that use the term. Future studies should explore public knowledge and understanding of the terms 'aerosol' and the more popular 'vapor' to better inform vaping risk communication.

How has the brain disease model of addiction contributed to tobacco control?

Our paper evaluates the extent to which the brain disease model of addiction (BDMA) has contributed to reducing the prevalence of tobacco smoking and  tobacco-related harm over the past 20 years. We discuss the ways in which genetic and neuroscience research on nicotine addiction have contributed to our understanding of tobacco smoking. We then examine the extent to which the BDMA has produced more effective treatments to assist smoking cessation. We also assess the degree to which the BDMA has contributed to the tobacco control policies that have produced substantial reductions in tobacco-related morbidity and mortality in the two decades since the model was first proposed by Alan Leshner. We also assess whether the BDMA has reduced the stigmatisation of people who smoke tobacco.

The changes in smoking stigmatization during the COVID-19 pandemic

Objectives

This study aimed to analyze the changes in smoking stigmatization in relation to an individual's smoking status after the COVID-19 outbreak.

Study design

A 2 (before vs. after COVID-19) X 2 (smoking status: smoker vs. non-smoker) factorial design was developed.

Methods

Two national surveys were conducted, one each before (between January 7th and 15th, 2020) and after (between January 26th and February 18th, 2021) the COVID-19 outbreak in South Korea. A total of 7296 representative adult responses were finalized. Respondents were categorized into two groups: non-smokers and smokers. Smoking stigma was measured in two ways: social and personal.

Results

In general, smoking stigmatization intensified after the COVID-19 outbreak. However, there was a discrepancy in responses based on smoking status-non-smokers exhibited a heightened negative stigma toward smokers, whereas smokers had generous perspectives about themselves.

Conclusions

The health-oriented environment generated by the response to COVID-19 is leading to increased stigmatization of smokers who pose a risk to public health. However, the discrepancy between smokers and non-smokers shows that social efforts are required to alter smokers' generous views about themselves and to persuade them to cease smoking.

Indexing Quit-Smoking Interest among Norwegian Smokers 2019-2021

Even if smoking prevalence is declining in several western countries, continued smoking cessation is required to reduce tobacco-related harms and to achieve future goals of smoke-free societies or the tobacco endgame. But how many of the current smokers want to quit? Estimates vary and depend on the type of question asked. We investigate how a pooled sample of Norwegian smokers (N = 1321) is distributed over four indicators of interest in quitting: (i) degree of desire to quit, (ii) prediction of future smoking status, (iii) reported plan for quitting smoking, and (iv) statements on previous attempts to quit. Based on these variables, we constructed an index. One-third of the smokers (32.6%) was categorized as having a high or very high interest in quitting. However, nearly half of the smokers (47.8%) had low or very low interest in quitting. Like several other countries, Norway has legislated a vision of a smoke-free society and, under the government's plans; this goal will be achieved by intensified use of structural measures such as tax hikes, tighter restrictions on outdoor smoking, and reduced availability of cigarettes. For the third who want to quit smoking, such constraints on their behaviour may help them to pursue their desire to quit. However, for the half who want to continue smoking, these measures may not be helpful but instead be experienced as a loss of welfare, less freedom to act, and increased social disqualification.

Environmental determinants of infectious and chronic disease prevention behaviours: A systematic review and thematic synthesis of qualitative research

Regulatory health policies facilitate desired health behaviours in communities, and among them, smoke-free policies and COVID-19 restrictions have been widely implemented. Qualitative research studies have explored how these measures and other environmental influences shape preventive behaviours. The objective of this systematic review was to synthesize previously published qualitative research, generate across-study themes, and propose recommendations for behaviour change interventions. We used a comprehensive search strategy, relevance screening and confirmation, data extraction, quality assessment, thematic synthesis, and quality-of-evidence assessment. In total, 87 relevant studies were identified. Findings were grouped under six overarching themes and mapped under three categories: (i) the political environment, (ii) the sociocultural environment, and (iii) the physical environment. These findings provide insights into the environmental influences of behaviour and indicate future interventions may be more effective by considering moral norms, community norms, policy support, and group identity.

Stigmatizing attitudes about lung cancer among individuals who smoke cigarettes

INTRODUCTION

Many individuals with lung cancer report experiencing stigma associated with their diagnosis. The objective of this study was to explore how different factors, including smoking status, lung cancer concern, and thoughts on smoking behaviors, were associated with increased stigmatizing attitudes towards people with lung cancer.

METHODS

In 2015, a Web-based survey was completed by people who currently smoked. Participants (n=1419) aged 18–65 years were randomly assigned to one of three scenarios in which the character who was diagnosed with lung cancer currently, formerly, or never smoked cigarettes. Two aspects of stigma were assessed: blaming the victim and negative attributions about people with lung cancer.

RESULTS

For blaming the victim and negative attributions, lung cancer stigma differed by scenario (described smoking status, p<0.0001), when adjusting for race, sex, education level, age, income, nicotine dependence, quit intentions, and quit attempts. Higher levels of lung cancer concern were associated with greater blaming the victim (p=0.001), when adjusting for scenario and other significant correlates.

CONCLUSIONS

The findings suggest that stigmatizing attitudes from people who smoke towards people with lung cancer may be reflective of how they feel about their own smoking habits. We suggest that specific messaging guidelines that avoid an over emphasis on an individual’s smoking status, cessation interventions that address stigma, and screening messages tailored to smoking status, may help to lessen the burden of lung cancer stigma.

Smoking and stress in the general population in Denmark

INTRODUCTION

The social pressure placed on smokers today might potentially lead to an increasing level of stress. We investigated if the proportion of persons with high stress level had increased over time more in smokers than in non-smokers.

METHODS

Data were obtained from repeated cross-sectional surveys of The Capital Region Health Survey conducted in 2010, 2013 and 2017. Survey data were weighted for survey design and non-response, and linked to national register data. Cohens Perceived Stress Scale (PSS-10) score was used. Logistic regression analyses, based on 136608 citizens’ self-reports, were adjusted for sex, age, education level, employment, and alcohol intake (and loneliness, in analysis investigating the associations between tobacco consumption and high stress level).

RESULTS

A significantly higher proportion of citizens reported a high stress level in 2017 compared with 2010 and 2013 but there was not a greater increase in smokers than in non-smokers. Daily smoking men had 69% higher odds of reporting perceived high stress level and daily smoking women had 36% higher odds, than never smokers of the same sex. There was a significant trend between higher daily tobacco consumption and a higher proportion of smokers with high stress level.

CONCLUSIONS

The increase in high stress level over time occurred independently of smoking status. Daily smokers had the highest odds of perceived high stress level, and a higher daily tobacco consumption was associated with a higher proportion of smokers with high stress level. Smoking cessation programs should, to a higher degree, consider implementing stress-coping elements to prevent relapse.

Bar Atmospherics and Smoking: A Qualitative Analysis of New Zealand Young Adult Smokers

INTRODUCTION

Smoking among young adults is often associated with social contexts and alcohol use. Although many countries, including New Zealand, have prohibited smoking inside licensed premises, outdoor areas have enabled smoking and alcohol co-use to persist. We examined whether and how outdoor bar areas facilitate and normalize young adult smoking and explored potential policy implications.

METHODS

We conducted in-depth interviews with 22 young adults who had recently smoked in a New Zealand bar or nightclub and investigated how physical design attributes (atmospherics) influenced experiences of smoking in outside bar settings. We used qualitative description to identify recurring accounts of the outdoor bar environment and thematic analysis to explore how participants experienced the bar in relation to smoking.

RESULTS

Participants valued outdoor smoking areas that were comfortable and relaxing, and saw attributes such as seating, tables, heating, protection from inclement weather, and minimal crowding, as important. We identified four themes; these explained how participants used smoking to gain respite and make social connections, showed how bar settings enabled them to manage smoking's stigma, and identified potential policy measures that would decouple smoking and alcohol co-use.

CONCLUSIONS

Evidence bar environments facilitate and normalize smoking among young adults questions whether smokefree policies should be expanded to include all bar areas. Introducing more comprehensive smokefree outdoor policies could reduce the influence of design attributes that foster smoking while also reframing smoking as outside normal social practice.

IMPLICATIONS

Bar environments contain many stimuli that cue and reinforce smoking and integrate smoking into social experiences. Expanding smokefree bar settings to include outdoor areas would reduce exposure to these stimuli, decrease opportunities for casual smoking, help maintain young people's smokefree status, and support longer-term goals of sustained reductions in smoking prevalence.

The Association Between Smoke-Free School Policies and Adolescents' Perceived Antismoking Norms: Moderation by School Connectedness

Introduction

Many European schools implement smoke-free school policies (SFSPs). SFSPs may decrease adolescent smoking by causing adolescents to perceive stronger antismoking norms, yet there exists no quantitative evidence that indicates for which norms and for whom such effects may occur. This study therefore assessed to what extent adolescents’ perceived antismoking norms among best friends, teachers, and society at large were associated with SFSPs, and whether these associations were moderated by adolescents’ level of school connectedness.

Aims and Methods

Survey data were collected in 2016/2017 on 10,653 adolescents aged 14–16 years old and 315 staff members in 55 schools from seven European cities. Associations of adolescent-perceived SFSPs and staff-reported SFSPs with best friend, teacher, and societal antismoking norms were estimated in multilevel logistic regression models, adjusted for demographics and school-level smoking prevalence. We tested for interaction between school connectedness and SFSPs.

Results

Adolescent-perceived SFSPs were positively associated with antismoking norms by teachers (odds ratio [OR]: 1.46, 95% confidence interval [CI]: 1.15–1.85), were negatively associated with antismoking norms by best friends (OR: 0.81, 95% CI: 0.67–0.99), but were not significantly associated with antismoking norms by society at large (OR: 0.87, 95% CI: 0.74–1.02). All interaction tests between adolescent-perceived SFSPs and school connectedness were nonsignificant. Staff-reported SFSPs were not associated with any norm and showed no significant interaction with school connectedness.

Conclusions

We found that SFSPs are associated with adolescents’ perception of more antismoking norms by teachers, but less antismoking norms by best friends, irrespective of adolescents’ level of school connectedness.

Implications

Smoke-free school policies, just as many other tobacco control policies, are assumed to foster adolescents’ perception of antismoking norms. Still, current evidence does not demonstrate which antismoking norms may be influenced by SFSPs and whether this influence is equal for adolescents with different levels of school connectedness. This study suggests that SFSPs foster adolescents’ perception of antismoking norms by teachers, but may concurrently lead to the perception of less antismoking norms by best friends, irrespective of adolescents’ school connectedness. SFSPs may therefore need to be complemented with interventions that target antismoking norms in adolescent peer groups.

Places to Smoke: Exploring Smoking-Related Practices among Danish Adolescents

Several established school smoking prevention initiatives involve restrictions on places to smoke. The focus on tobacco control in schools is due to the risk of smoking initiation during adolescence and the perception of this life stage as a period of time when health behavior is established. Hence, this period of time is considered to be ideal for health-promoting initiatives. This paper is part of an ethnographic study on adolescents' perceptions of tobacco use. Focus groups and field observations were used to explore adolescents' smoking-related practices related to smoking bans at schools. The findings show that smoking, as a place-based practice, is influenced by locally embedded rules and carries social implications resulting in a distinction between smokers and non-smokers. The distinction between smokers and non-smokers contributes to the retention of a stereotypical view of smokers and, moreover, stigmatizes smokers. According to this, restrictions on places to smoke within the school should be considered carefully in order to avoid stigma or ethical issues.

Trends in the psychosocial characteristics of 11-15-year-olds who still drink, smoke, take drugs and engage in poly-substance use in England

INTRODUCTION AND AIMS

Youth substance use is declining in many high-income countries. As adolescent substance use becomes less common, it may concentrate in higher-risk groups. This paper aims to examine how the psychosocial characteristics of young substance users in England have changed over time.

DESIGN AND METHODS

Annual cross-sectional data from the 2001-2014 Smoking, Drinking and Drug Use Among Young People in England survey are analysed (n = 112 792, age: 11-15). Logistic and Poisson regression analyses are used to test whether the sex, socioeconomic status (SES) and prevalence of truancy and exclusion from school of those who drink alcohol, smoke cigarettes, take cannabis, take other drugs and engage in poly-substance use changed across the study period.

RESULTS

Use of all substances decreased and there were shifts in the psychosocial characteristics of young smokers, illicit drug users and poly-substance users. The proportion of current smokers and ever-users of cannabis of low SES and who had been excluded increased significantly between 2001/2003-2014. The proportion of last month drug users who had been excluded from school also increased significantly and there were increases in the proportion of polysubstance-users who had truanted and been excluded. The proportion of low SES alcohol users who had been excluded also increased significantly, but this change was very small. There was no evidence of substance use becoming more or less concentrated in one gender.

DISCUSSION AND CONCLUSIONS

There is some evidence that smoking, illicit drug use and poly-substance use are becoming more concentrated in potentially at risk populations. There is limited evidence of concentration amongst young drinkers.

Are smoking cessation behaviours among daily smokers associated with a perceived public stigma of smokers? Cross-sectional analyses of Norwegian data 2011–2013

Introduction

Perceived stigma may be an unintended consequence of tobacco denormalization policies among remaining smokers. Little is known about the role of perceived stigmatization in cessation behaviours.

Aims

To test if perceived public smoker stigma is associated with recent attempts to cease smoking and future cessation plans among adult daily smokers.

Methods

Using merged data from the biennial national survey Norwegian Monitor 2011 and 2013 (N daily smokers = 1,029), we performed multinomial and ordinal regression analyses to study the impact of perceived public stigma (measured as social devaluation and personal devaluation) on recent quit attempts, short-term intention to quit and long-term intention to quit, controlling for confounders. One additional analysis was performed to investigate the relationship between stigma and intention to quit on quit attempts.

Results

A significant association between perceived social devaluation and recent quit attempts was found (OR 1.76). Perceived stigma was not associated with future quit plans. Personal devaluation was not associated with any cessation outcome. The role of perceived social devaluation on quit attempts was mainly found among smokers with intentions to quit.

Conclusion

These findings indicate that stigma measured as social devaluation of smokers is associated with recent quit attempts, but not with future quit plans.

Experiences of tobacco cessation including a prescription approach among patients in Swedish primary health care with a focus on socioeconomically disadvantaged areas

Background

Tobacco Cessation on Prescription (TCP) is a new intervention that is being evaluated in socioeconomically disadvantaged areas in Swedish primary health care (PHC). Patients’ perceptions of TCP are important to understand as this may have implications for the acceptability and adherence to treatment and explain cessation outcomes. Patients’ general experiences of tobacco cessation are also important to explore to improve cessation support in this setting.

Aim

To explore experiences of tobacco cessation and TCP among patients in Swedish PHC focusing on socioeconomically disadvantaged areas.

Methods

Inductive content analysis of transcripts from eight semi-structured interviews with patients recruited from the intervention group in a randomized controlled trial evaluating the effectiveness of TCP in socioeconomically disadvantaged areas in PHC in Stockholm.

Results

Two themes were identified: needing individualized support to quit, taking differences in patients’ experiences of tobacco use and cessation into account, acknowledging individual factors such as impact of health and wellbeing on tobacco use and differing attitudes towards tobacco and cessation and needing a supportive environment to facilitate tobacco cessation, taking contextual factors like professional support from the health care system, the importance of the social environment and supportive societal structures into account. Regarding TCP, the prescription form was perceived as useful for providers but did not appear to have a direct impact on tobacco cessation from the informants’ perspective. However, individualized counseling from a tobacco cessation specialist, an empathetic approach in the treatment and long-term follow-up was considered important.

Conclusion

A holistic approach may be needed in cessation treatment, combined with interventions outside the health care system, to facilitate tobacco cessation among patients in socioeconomically disadvantaged areas in Swedish PHC. The TCP prescription form may be helpful for PHC providers but counseling and follow-up appear to be the most important components of TCP for patients in this setting.

Smoking-Related Stigma: A Public Health Tool or a Damaging Force?

BACKGROUND

Tobacco control policies and other denormalization strategies may reduce tobacco use by stigmatizing smoking. This raises an important question: Does perceived smoking-related stigma contribute to a smoker's decision to quit? The aim of this study was to evaluate if perceived smoking-related stigma was associated with smoking cessation outcomes among smokers in Mexico and Uruguay.

METHODS

We analyzed prospective data from a panel of adult smokers who participated in the 2008-2012 administrations of the International Tobacco Control Policy Evaluation Surveys in Mexico and Uruguay. We defined two analytic samples of participants: the quit behavior sample (n = 3896 Mexico; n = 1525 Uruguay) and the relapse sample (n = 596 Mexico). Generalized estimating equations were used to evaluate if different aspects of perceived stigma (ie, discomfort, marginalization, and negative stereotype) at baseline were associated with smoking cessation outcomes at follow-up.

RESULTS

We found that perceived smoking-related stigma was associated with a higher likelihood of making a quit attempt in Uruguay but with a lower likelihood of successful quitting in Mexico.

CONCLUSIONS

This study suggests that perceived smoking-related stigma may be associated with more quit attempts, but less successful quitting among smokers. It is possible that once stigma is internalized by smokers, it may function as a damaging force. Future studies should evaluate the influence of internalized stigma on smoking behavior.

IMPLICATIONS

Although perceived smoking-related stigma may prompt smokers to quit smoking, smoking stigma may also serve as a damaging force for some individuals, making quitting more difficult. This study found that perceived smoking-related stigma was associated with a higher likelihood of making a quit attempt in Uruguay but with a lower likelihood of successful quitting in Mexico.

Qualitative examination of the perceived effects of a comprehensive smoke-free law according to neighborhood socioeconomic status in a large city

Smoke-free legislations aim to protect non-smokers from second-hand smoke (SHS) exposure and improve population health outcomes. The aim of this study was to explore residents' perceptions to understand how people living in distinctive SES neighborhoods are differently affected by comprehensive smoke-free laws in a large city like Madrid, Spain. We conducted a qualitative project with 37 semi-structured interviews and 29 focus group discussions in three different SES neighborhoods within the city of Madrid. Constructivist grounded theory was used to analyze the transcripts. One core category arose in our analyses: Neighborhood inequalities in second-hand smoke (SHS) exposure in outdoor places. The enactment of the comprehensive smoke-free law resulted in unintended consequences that affected neighborhoods differently: relocation of smokers to outdoor setting, SHS exposure, noise disturbance and cigarette butt littering. Changes in the urban environment in the three neighborhoods resulted in the denormalization of smoking in outdoor public places, which was more clearly perceived in the high SES neighborhood. Changes in the built environment in outdoor areas of hospitality venues were reported to actually facilitate smoking. Comprehensive smoke-free laws resulted in denormalization of smoking, which might be effective in reducing SHS exposure. Extending smoking bans to outdoor areas like bus stops and hospitality venues is warranted and should include a public health inequalities perspective.

Stigma and Smoking in the Home: Parents' Accounts of Using Nicotine Replacement Therapy to Protect Their Children from Second-Hand Smoke

Evidence and campaigns highlighting smoking and second-hand smoke risks have significantly reduced smoking prevalence and denormalised smoking in the home in Scotland. However, smoking prevalence remains disproportionally high in socioeconomically disadvantaged groups. Using stigma as a theoretical lens, this article presents a thematic analysis of parents' accounts of attempting to abstain from smoking at home, using nicotine replacement therapy (NRT), in disadvantaged areas of Edinburgh and the Lothians. Smoking stigma, particularly self-stigma, underpinned accounts, with two overarching themes: interplaying barriers and enablers for creation of a smoke-free home and reconceptualisation of the study as an opportunity to quit smoking. Personal motivation to abstain or stop smoking empowered participants to reduce or quit smoking to resist stigma. For those struggling to believe in their ability to stop smoking, stigma led to negative self-labelling. Previously hidden smoking in the home gradually emerged in accounts, suggesting that parents may fear disclosure of smoking in the home in societies where smoking stigma exists. This study suggests that stigma may act both as an enabler and barrier in this group. Reductions in smoking in the home were dependent on self-efficacy and motivations to abstain, and stigma was entwined in these beliefs.

A qualitative study of e-cigarette emergence and the potential for renormalisation of smoking in UK youth

BACKGROUND

Growth of e-cigarette use among smokers has raised concerns over uptake by non-smokers, particularly young people. Legislative changes aimed in part at reducing youth exposure to e-cigarettes include the EU Tobacco Products Directive (TPD). A core justification for such measures is the belief that e-cigarettes can lead to tobacco smoking through mechanisms of renormalisation including: mimicking and normalizing the act of smoking; increasing product acceptability via marketing; nicotine exposure. These mechanisms are here explored in relation to findings from qualitative research.

METHODS

This paper reports results from twenty-one group interviews with 14-15 year olds in Wales, England and Scotland, conducted as part of an ongoing evaluation of the impact of the TPD on youth smoking and e-cigarette use. Interviews were conducted around the end of the transitional period for TPD implementation, and explored perceptions of e-cigarettes and tobacco, as well as similarities and differences between them.

RESULTS

Young people differentiated between tobacco and e-cigarettes, rejecting the term e-cigarette in favour of alternatives such as 'vapes'. Experimental or occasional use was common and generally approved of where occurring within social activity with peers. However, regular use outside of this context was widely disapproved of, unless for the purpose of stopping smoking. Increased prevalence of e-cigarettes did not challenge strongly negative views of smoking or reduce perceived harms caused by it, with disapproval of smoking remaining high. Nicotine use was variable, with flavour a stronger driver for choice of e-liquid, and interest more generally.

CONCLUSION

The extent to which participants differentiated between vaping and smoking, including styles and reasons for use in adults and young people; absence of marketing awareness; and continued strong disapproval of smoking provides limited support for some of the potential mechanisms through which e-cigarettes may renormalise smoking. However caution over nicotine exposure is still necessary.

Perceptions of Financial Incentives for Smoking Cessation: A Survey of Smokers in a Country With an Endgame Goal

Introduction

Financial incentives can support smoking cessation, yet low acceptability may limit the wider implementation of such schemes. Few studies have examined how smokers view financial-incentive interventions aimed at reducing smoking prevalence.

Methods

We recruited a sample of 623 smokers from an internet panel to a survey assessing support for, and perceived effectiveness of, financial incentives for smoking cessation. We used descriptive statistics, plus logistic regression, to test associations between demographics and smoking, and support. We used qualitative content analysis to analyze open-ended responses to a question that invited respondents to comment on financial incentives.

Results

Financial incentives were supported by 38.4% of smokers; 42.2% did not support and 19.4% had no opinion. Support was higher among heavy (OR = 3.96, 95% CI = 2.39 to 6.58) and moderate smokers (OR = 1.68, 95% CI = 1.13 to 2.49), and those with a recent quit attempt (OR = 1.47, 95% CI = 1.04 to 2.07). Support was strongly associated with perceived effectiveness. A Government-funded reward-only scheme was seen as the most acceptable option (preferred by 26.6% of participants), followed by a Government-funded deposit-based scheme (20.6%); few respondents supported employer-funded schemes. Open-ended responses (n = 301) indicated three overarching themes expressing opposition to financial incentives: smokers' individual responsibility for quitting, concerns about abuse of an incentive scheme, and concerns about unfairness.

Conclusion

Even amongst those who would benefit from schemes designed to reward smokers for quitting, support for such schemes is muted, despite the evidence of their effectiveness. Media advocacy and health education could be used to increase the understanding of, and support for, financial incentives for smoking cessation.

Implications

Given the absolute effectiveness and cost effectiveness of financial-incentive schemes for smoking cessation amongst pregnant smokers and in workplaces, implementing such schemes at a national-level could help reduce overall smoking prevalence and contribute to endgame goals. Our study found that similar proportions of smokers supported and opposed financial-incentive schemes and suggests that much of the opposition was underpinned by information gaps, which could be addressed using education and media advocacy.

"I'm Scared of the Disappointment": Young Adult Smokers' Relational Identity Gaps and Management Strategies as Sites of Communication Intervention

While cigarette smoking is decreasing among young adults, rates of nicotine consumption through other devices, most notably electronic cigarettes, are on the rise. Framed by communication theory of identity, this study examines young adult smokers' experiences with relational others in regard to their smoking. Focus group discussions and individual interviews convened with 20 young adult cigarette and electronic cigarette smokers revealed identity gaps implicating the relational layer of identity, including personal-relational, enacted-relational, and personal-enacted-relational identity gaps. Participants used communicative and behavioral strategies to manage relational discrepancies. The documented identity gaps and management strategies present opportunities for targeted smoking cessation interventions that amplify dissonance created through identity gaps as a motivational tactic.

Is Smoking Queer? Implications of California Tobacco Denormalization Strategies for Queer Current and Former Smokers

This article is concerned with normative conceptions of health structuring tobacco control strategies designed to "denormalize" tobacco use. Analysis of 201 interviews with non-heterosexual and/or non-cisgender adults in California revealed that participants implicated tobacco use in exacerbating health inequities and perpetuating harmful narratives of queer suffering, but also regarded smoking as a critical tool for self-care and symbol of resistance. Participant narratives suggest that using stigma in health promotion efforts which reinforce normative conceptions of health may be harmful to queer people whose social identities exist within ongoing legacies of pathology, health stigma, and deviance from hegemonic structural norms.

"They're thinking, well it's not as bad, I probably won't get addicted to that. But it's still got the nicotine in it, so…": Maturity, Control, and Socializing: Negotiating Identities in Relation to Smoking and Vaping-A Qualitative Study of Young Adults in Scotland

Objective

To explore the understandings of and engagement with e-cigarettes, of young adults from disadvantaged backgrounds, and how these may have an impact on existing smoking identities.

Methods

Twenty-two small group and 11 individual qualitative interviews were conducted in Central Scotland with 72 16-24 year olds between September 2015 and April 2016. Participants were mostly smokers and ex-smokers from socioeconomically disadvantaged backgrounds.

Results

Although most participants had tried e-cigarettes, they generally held ambivalent views about e-cigarettes and vaping. Two overarching themes were identified which helped in understanding this. Firstly, e-cigarettes were understood by the participants in relation to their existing smoking identities. Vaping was viewed as less controllable and more addictive than smoking, which did not fit with their self-identity as controlled smokers. Secondly, they felt that vaping could not replace the social and cultural importance that smoking had in their lives.

Conclusion

This study suggests that though young adults from disadvantaged areas are trying e-cigarettes for various reasons, vaping is rarely sustained. Through their own experiences of vaping and their observations of others vaping, the participants perceive the behavior as endangering an existing acceptable and controlled smoking identity. Additionally, e-cigarettes were considered to be a jarring presence in existing social situations where smoking was valued. This study, therefore, provides insights into how young adults may be rationalizing their continued smoking in the face of potentially less harmful alternatives.

Implications

As new and novel nicotine delivery devices, and due to their similarity to smoking, e-cigarettes have the potential to help smokers in their quit attempts. However, the findings from this study raise questions about whether e-cigarettes are regarded as having this potential by young adult smokers from disadvantaged socioeconomic environments where smoking is more commonplace and acceptable.

Anti-smoking social norms are associated with increased cessation behaviours among lower and higher socioeconomic status smokers: A population-based cohort study

BACKGROUND

Social denormalisation of smoking can provide an environment that helps smokers to quit. This study examined which of three measures of anti-smoking social norms have the greatest influence on quitting-related cognitions and behaviours, and if this influence differs according to socioeconomic status (SES).

METHODS

The Victorian Tracking Survey measured social norms among 1,348 (n(weighted) = 1,373) Australian adult smokers (aged 18-59) between 2012 and 2014, who were followed-up one week later. Weighted logistic regression analyses examined prospective associations of baseline subjective (family and friends' disapproval of smoking), injunctive (feeling embarrassed about being a smoker) and descriptive norms (living with someone who tried to quit in the past 12 months), with quitting-related cognitions and behaviours at follow-up. Data were weighted to account for telephony status (landline or mobile phone), sex and age. Analyses were adjusted for demographic characteristics, addiction level, tobacco control policies and quitting-related outcomes measured at baseline. Differences in associations between lower and higher SES smokers (based on educational attainment and area-based disadvantage) were examined through interaction terms and stratified analyses.

RESULTS

Sixty-four percent of participants (n(weighted) = 872) perceived disapproval from family and friends, 31% (n(weighted) = 419) felt embarrassed to be a smoker, and 11% (n(weighted) = 155) lived with a recent quitter. All three norms were associated with having set a firm date to quit in the next month and with engaging in smoking limiting behaviours. Embarrassment was also associated with an increased likelihood of talking about quitting and with making a quit attempt. Associations were mostly comparable for lower and higher SES smokers, with no significant negative rebound effects overall or among subgroups.

CONCLUSIONS

These findings indicate close others' disapproval and feelings of embarrassment most strongly motivate smokers to try to quit. If tobacco control policies or media campaigns further denormalise smoking, there should be no reason for concern that such denormalisation undermines cessation behaviours.

The Role of Multiple Social Identities in Discrimination and Perceived Smoking-Related Stigma among Sexual and Gender Minority Current or Former Smokers

AIMS

We investigated how intersections of being a racial minority (i.e. being African American) and economically-disadvantaged (i.e. housing insecurity) may influence experiences with discrimination and perceptions of smoking-related stigma among sexual and gender minority (SGM) current and former smokers. Methods: Survey data were collected from 227 SGM current and former smokers in California (19-65 years old), oversampling African American participants. Participants reported their race, ethnicity, past month housing insecurity, number of lifetime experiences with SGM discrimination, and perceptions of smoking-related stigma.

FINDINGS

Using univariate General Linear Models and controlling for age, ethnicity, and SGM visibility, we found a significant interaction between being African American and facing housing insecurity on experiences with SGM discrimination [F(1,220)=7.21, p=0.01], perceived smoker stigma [F(1,220)=5.48, p=0.02], perceived differential treatment due to smoking [F(1,220)=10.03, p=0.00], and social withdrawal from non-smokers [F(1,220)=6.18, p=0.01]. These interactions suggest that economically-disadvantaged African American SGM current or former smokers experience increased levels of discrimination and perceive more smoking-related stigma compared to other SGM current and former smokers. Conclusions: Results suggest that people's multiple identities intersect to intensify oppression and inequities for some people and raise questions about the unintended consequences of stigmatizing smokers for reducing smoking among SGM adults.

E-cigarettes, vaping and performativity in the context of tobacco denormalisation

E-cigarettes are devices through which a nicotine solution is 'vapourised' and inhaled by the user. Unlike cigarettes, the process involves no tobacco combustion. However, the inhalation and exhalation of vapour is reminiscent of smoking and there is debate about the possible harms and benefits of e-cigarette use, including the 'renormalisation' of smoking. Despite these debates, there has been little exploration into the embodied and semiotic similarities between smoking and vaping. This paper views the practices of vaping and smoking through the lens of performativity that is, the accumulation of meaning associated with the habits over time and space. Through in-depth interviews, we explore how young adults from primarily disadvantaged areas in Scotland, understand the similarity in practices between smoking and vaping. Participants talked about financial barriers to using different types of e-cigarettes, and how their use reflected their views on smoking cessation. They also discussed the embodied similarities between smoking and vaping, with divergent opinions on whether this continuance of habit was beneficial or not, revealing still developing and ambiguous norms around performativity. The norms of vaping were also frequently discussed, with participants' experiences and views reflecting the contested position of vaping in an environment where cigarette smoking is denormalised.

Does Stigmatization Motivate People to Quit Smoking? Examining the Effect of Stigmatizing Anti-Smoking Campaigns on Cessation Intention

Stigmatization against smokers characterizes many of today's anti-smoking campaigns in the United States. It is believed that stigmatization motivates people to quit smoking by arousing a state of emotional distress, such as shame, in viewers. However, stagnant cessation rates among socioeconomically disadvantaged smokers imply that stigmatizing campaigns might be ineffective in promoting cessation among those low in socioeconomic status. To understand the effectiveness of stigmatizing campaign messages, we proposed a moderated mediation model and experimentally tested it among current smokers (n = 136). Results show that exposure to a stigmatizing message significantly lowered smokers' cessation intentions who have lower income and less self-efficacy. The conditional negative effect of the message was accounted for by shame experienced by smokers.

How will e-cigarettes affect health inequalities? Applying Bourdieu to smoking and cessation

This paper uses the work of Bourdieu to theorise smoking and cessation through a class lens, showing that the struggle for distinction created the social gradient in smoking, with smoking stigma operating as a proxy for class stigma. This led to increased policy focus on the health of bystanders and children and later also to concerns about electronic cigarettes. Bourdieu's concept of habitus is deployed to argue that the e-cigarette helps middle-class smokers resolve smoking as a symptom of cleft habitus associated with social mobility or particular subcultures. E-cigarette use is also compatible with family responsibility and sociable hedonism; aspects of working-class habitus which map to the 'practical family quitter' and the 'recreational user' respectively. The effectiveness of class stigma in changing health behaviours is contested, as is the usefulness of youth as a category of analysis and hence the relevance of concerns about young people's e-cigarette use outside a class framework of smoking and cessation. With regard to health inequalities, whilst middle-class smokers have in class disgust a stronger incentive to quit than working-class smokers, there is potential for tobacco control to tap into a working-class ethos of family care and responsibility.

Smoking to fit a stigmatised identity? A qualitative study of marginalised young people in Australia

In countries with comprehensive tobacco control, smoking is increasingly denormalised, with smokers subject to social stigmatisation. Qualitative research and commentary about denormalisation and stigma has largely focused on the impact on current or former smokers. Little attention has been given to the interaction between existing stigma among socially marginalised and disadvantaged young people and its role in smoking uptake, maintenance and resistance to quitting, or remaining a non-smoker. This article draws on a qualitative (grounded theory) study of young people aged 16-25 years who attended social services for at-risk youth in an inner city area in Australia, to explore the intersection between stigmatised identity and smoking in a context of increasing smoking denormalisation. Drawing on theoretical conceptualisations of stigma, we outline processes by which participants accept and apply social labels, internalise or distance themselves from stigmatised identities, and the influence of labelling on smoking trajectories, to demonstrate how the persistent dilemma of stigma shapes and reinforces smoking behaviour. The study highlights the need for tobacco control initiatives to align and integrate with broader initiatives to address structural inequality and social disadvantage.

A typology of vaping: Identifying differing beliefs, motivations for use, identity and political interest amongst e-cigarette users

BACKGROUND

The aim of this study was to identify and differentiate socially shared accounts of e-cigarette use (vaping) using Q-methodology, combining factor analysis with qualitative comments.

METHODS

Seventy statements on e-cigarettes, drawn from media, academic and online discussions, were sorted by participants along a continuum of agreement/disagreement, commenting on strongly ranked items. Each participant thus created their own 'account' of their vaping. A by-person correlation matrix of the sorts was conducted, then factor analysed, to identify similar accounts (p<0.01). Fifty-five UK vapers participated by post, 55% male, mean age of 46, 84% only vaping/16% vaping and smoking, 95% vaping daily.

RESULTS

Three accounts of e-cigarettes were identified. The first two were associated with having quit smoking; the third with ongoing tobacco smoking and vaping. In Factor One, 'Vaping as Pleasure', vaping was characterized as enjoyable, with long-term use envisaged and a medical model of vaping rejected. Factor One participants also held a strong vaping identity and were politically motivated to maintain the rights of adults to vape. In Factor Two, 'Vaping as Medical Treatment', vaping was understood as a pragmatic choice about how to medicate one's smoking addiction, with the aim being to treat and ultimately reduce nicotine dependence. In Factor Three, 'Ambivalent E-Cigarette Use', participants reported fewer benefits and harboured more negative beliefs about e-cigarettes; they also strongly rejected a vaper identity, having no interest in online forums or being labelled a 'vaper' themselves.

CONCLUSION

The UK e-cigarette users in this sample were not a homogeneous group; differing in their beliefs, motivations for use, identity and political interest. In particular they diverged on whether they accepted a medicalized account of vaping and identified as a vaper. Public health messages targeted to one group of e-cigarette users may not resonate with others.

An Intersectional Analysis of Women's Experiences of Smoking-Related Stigma

In this article, we explore how young women encounter and counter discourses of smoking-related stigma. Twenty-seven young Australian women, smokers and ex-smokers, took part in interviews. A sub-sample of 18 participants took photographs to document their smoking experience, and took part in a second interview. Data were analyzed through Foucauldian discourse analysis. Four discourses were identified: "smoking as stigmatized," "the smoking double standard," "smoking as lower class," and "smokers as bad mothers." The women negotiated stigma in a variety of ways, shifting between agreeing, disagreeing, challenging, and displacing stigma onto "other" smokers. These experiences and negotiations of smoking-related stigma were shaped by intersecting identities, including gender, cultural background, social class, and mothering, which at times, compounded levels of stigmatization. It is concluded that tobacco control measures should consider the negative implications of smoking-related stigma, and the potential for women to experience compounding levels of stigma.

Qualitative analysis of young adult ENDS users' expectations and experiences

OBJECTIVES

Despite extensive research into the determinants of electronic nicotine delivery system (ENDS) uptake, few studies have examined the psychosocial benefits ENDS users seek and experience. Using a consumer ritual framework, we explored how ENDS users recreated or replaced smoking practices, and considered implications for smoking cessation.

DESIGN

In-depth interviews; data analysed using thematic analysis.

SETTING

Dunedin, New Zealand.

PARTICIPANTS

16 young adult ENDS users (age M=21.4, SD=1.9; 44% female).

RESULTS

Participants reported using different ENDS to achieve varying outcomes. Some used 'cigalikes' to recreate a physically and visually similar experience to smoking; they privileged device appearance over nicotine delivery. In contrast, others used personally crafted mods to develop new rituals that differentiated them from smokers and showcased their technical expertise. Irrespective of the device they used, several former smokers and dual users of cigarettes and ENDS experienced strong nostalgia for smoking attributes, particularly the elemental appeal of fire and the finiteness of a cigarette. Non-smoking participants used ENDS to maintain social connections with their peers.

CONCLUSIONS

Participants used ENDS to construct rituals that recreated or replaced smoking attributes, and that varied in the emphasis given to device appearance, nicotine delivery, and social performance. Identifying how ENDS users create new rituals and the components they privilege within these could help promote full transition from smoking to ENDS and identify those at greatest risk of dual use or relapse to cigarette smoking.

'Betwixt and between health and illness' - women's narratives following acute coronary syndrome

AIMS AND OBJECTIVES

This study investigated experiences of women with a primary diagnosis of ACS (NSTEMI and Unstable Angina) in the 6-8 week period following discharge from hospital. The aim was to report the experience of the mediating impact of a newly-diagnosed disease.

BACKGROUND

Cardiovascular disease is the main cause of mortality in women. Treatment modalities have improved health outcomes and survival rates, however, quality of life and ongoing morbidity after discharge is not clearly understood from a gender specific perspective.

DESIGN

A naturalistic case study design guided this study.

METHODS

Thirty women participated (n = 30); a within-case followed by a cross-case analysis provided meticulous knowledge of each case. Data collection included participant diaries and face to face interviews. Data were analysed using modified analytic induction which allowed the emergence of theoretical insights. The theoretical concepts, liminality and transitioning were used to inform the analysis. Within-methods triangulation captured the depth and breadth of the women's experiences.

RESULTS

The data provide an insight into women's experiences following ACS and highlight a need for support structures and services after discharge. Many women reported a period of disrupted normality following discharge from hospital. While a number of women had transitioned towards recovery, many remained in a liminal space 'betwixt and between' health and illness. Cardiac rehabilitation was reported as a positive experience for those who were attending.

CONCLUSIONS

The findings provide a platform for a wider discourse on the needs of women with ACS in the immediate period after discharge from hospital. Women may benefit from gender-specific, appropriately timed, and targeted interventions to facilitate recovery and adaptation to living with CHD.

RELEVANCE TO CLINICAL PRACTICE

It is essential that secondary prevention services are modelled and tailored to meet the needs of women and evaluated appropriately to ensure positive outcomes. Nursing could have a key role to play in managing and providing this support.

Can reflexivity be learned? An experience with tobacco control practitioners in Canada

Summary

To explore an example of a reflexive intervention with health professionals working in tobacco control (TC). This study reports the perceived intervention effects regarding: (i) participants' understanding of reflexivity and personal learning and (ii) conditions needed in order to integrate reflexivity into professional and organizational practices. This is a qualitative study using an interpretative evaluation framework to assess the perceived effects of a reflexive intervention in Montréal, Québec. Semi-structured qualitative interviews (n = 8) gathered data. Data analysis began deductively, guided by the broad categories found in research questions. Sub-categories to populate these broad categories captured the inhibitors and facilitators through an inductive thematic analysis. Our study reveals that, following the intervention, most participants had a generally good understanding of reflexivity and described concrete learning in association with the intervention. Main facilitators and inhibitors to conducting a reflexive workshop pertained to the organizational context as well as to the professional and individual characteristics of the participants. Some participants implemented sustainable changes as a result of the intervention, such as creating a tool, reviewing work plans and developing new mechanisms to integrate the voice of their clientele in the planning process. The need and interest for dialogue among health professionals about how TC intervention activities may inadvertently contribute to social inequalities in smoking is apparent. While there appears to be potential for reflexive practice, the integration of reflexivity into practice is reliant upon the organizational context (financial and time constraints, culture, support, and climate) and the reflexivity concept itself (intangibility, complexity and fuzziness).

‘I Sat Filling in This Form While Smoking and It Was Divine’. An Analysis of Free-Text Comments from Smokers Who Report They Have No Intention of Quitting in the Next Six Months

Introduction: Smokers unmotivated to quit are neglected by smoking cessation research. Free-text comment analysis is a potentially useful way to gain insight into this group's beliefs.

Aims: To analyse the free-text comments provided by smokers unmotivated to quit as part of a randomized controlled trial of computer-tailored feedback for smoking cessation.

Method: A random sample of 58,660 smokers were sent a smoking behaviour questionnaire (SBQ). The responses and follow-up outcomes of those providing free-text comments were compared to those who did not to assess the representativeness of the former group of smokers. The comments of participants unmotivated to quit (631) were thematically analysed.

Results: Those who provided a comment differed from those who did not on variables including education level and quit attempts at six-month follow-up. Emergent themes included; justification of smoking and restricting smoking instead of quitting.

Conclusions: The findings illustrate the value of free-text comments in identifying issues important to respondents. The identified themes highlight areas for future research in smokers unmotivated to quit including cutting down as a path to quitting and explicit messages regarding the inability of positive health behaviours to balance out the negative impact of smoking on health.

Trial registration: Current Controlled Trials ISRCTN05385712.

Stigmatic and Sympathetic Attitudes Toward Cancer Patients Who Smoke: A Qualitative Analysis of an Online Discussion Board Forum

INTRODUCTION

A significant minority of patients continue to smoke after a cancer diagnosis. Cancer patients who smoke experience stigma that can negatively impact health outcomes. We explored publicly shared perspectives about cancer patients who continued to smoke post-diagnosis.

METHODS

An online news article, published in January 2012, summarized the findings of smoking prevalence among patients with lung cancer and colorectal cancer enrolled in the Cancer Care Outcomes Research and Surveillance Consortium trial. In response, written comments were posted on the articles' public discussion board. Applying principles of grounded theory, we conducted a document analysis and established a conceptual framework to develop a model by which to explain factors underlying stigmatic and sympathetic attitudes toward cancer survivors who continue to smoke.

RESULTS

Personal experiences with cancer, smoking, and statistical literacy were found to influence beliefs about cancer and smoking, which in turn influenced stigmatic or sympathetic attitudes. More sympathetic attitudes were expressed by individuals who had personal experiences with smoking, believed cancer is multicausal, identified smoking as an addiction, or considered extrinsic factors responsible for smoking. Individuals who did not have personal experiences with cancer or smoking, had low statistical literacy, believed that smoking necessarily and directly causes cancer, and focused on intrinsic responsibilities for smoking tended to express more stigmatic attitudes.

CONCLUSIONS

The current findings raise awareness and provide insight into stigma against cancer survivors who smoke and can help inform strategies for reducing stigma against this vulnerable group.

IMPLICATIONS

This study helps raise awareness of stigma toward cancer patients who smoke and provides insight into the processes that may influence stigmatic as compared to sympathetic attitudes toward these patients. Results suggest that population-based strategies to educate the public regarding the nature of nicotine addiction, difficulty of quitting, and benefits of quitting for cancer patients may be useful for reducing stigma against cancer patients with a smoking history.

Smoke-free hospital site conversations: how nurses can initiate change

Smoking tobacco continues to be the world's most preventable cause of death and disability with over six trillion cigarettes sold each year. Patients, visitors and health professionals who smoke on hospital sites present a challenge to the effectiveness of public health messages. Health professionals who ignore 'No smoking' hospital/clinic signage, and avoid smoking-cessation activity, help to sustain the perception that smoking is tolerated. Case studies, with a focus on lung cancer and chronic obstructive pulmonary disease (COPD), are used to illustrate how nurses can 'seed' the idea of hospitals becoming smoke-free, provide brief interventions and support patients, carers and colleagues to make that change.

The neurobiological and behavioral overlaps of nicotine and food addiction

Both cigarette smoking and obesity are significant public health concerns and are associated with increased risk of early mortality. It is well established that the mesolimbic dopamine pathway is an important component of the reward system within the brain and is implicated in the development of addiction. Indeed, nicotine and highly palatable foods are capable of altering dopamine release within this system, engendering addictive like responses in susceptible individuals. Although additional research is warranted, findings from animal and human literature have elucidated many of neuroadaptions that occur from exposure to nicotine and highly palatable foods, leading to a greater understanding of the underlying mechanisms contributing to these aberrant behaviors. In this review we present the findings taken from preclinical and clinical literature of the known effects of exposure to nicotine and highly palatable foods on the reward related circuitry within the brain. Further, we compare the neurobiological and behavioral overlaps between nicotine, highly palatable foods and obesity. Lastly, we examine the stigma associated with smoking, obesity and food addiction, and the consequences stigma has on the overall health and wellbeing of an individual.

Smoking on the margins: a comprehensive analysis of a municipal outdoor smoke-free policy

BACKGROUND

This study examined the formulation, adoption, and implementation of a ban on smoking in the parks and beaches in Vancouver, Canada.

METHODS

Informed by Critical Multiplism, we explored the policy adoption process, support for and compliance with a local bylaw prohibiting smoking in parks and on beaches, experiences with enforcement, and potential health equity issues through a series of qualitative and quantitative studies.

RESULTS

Findings suggest that there was unanimous support for the introduction of the bylaw among policy makers, as well as a high degree of positive public support. We observed that smoking initially declined following the ban's implementation, but that smoking practices vary in parks by location. We also found evidence of different levels of enforcement and compliance between settings, and between different populations of park and beach users.

CONCLUSIONS

Overall success with the implementation of the bylaw is tempered by potential increases in health inequities because of variable enforcement of the ban; greatest levels of smoking appear to continue to occur in the least advantaged areas of the city. Jurisdictions developing such policies need to consider how to allocate sufficient resources to enhance voluntary compliance and ensure that such bylaws do not contribute to health inequities.

Smoke and Vapor: Exploring the Terminology Landscape among Electronic Cigarette Users

OBJECTIVE

We explored the terminology of adult e-cigarette users in describing e-cigarette products and their use. We report how users discuss and differentiate these products and the language and culture surrounding them.

METHODS

Focus groups (N = 12) were held in 5 locations in the United States between March and May, 2014. Participants (N = 99) included young adults or adults who were either exclusive or nonexclusive e-cigarette users. We gathered data on how users identify various types of e-cigarettes and how users understand and describe specific terms.

RESULTS

Participants were familiar with the attributes of e-cigarettes in general but confused by the variety of products and unable to describe differences between product types. They were familiar with the term "vaping" even when they used "smoking" more frequently, and were clear that e-cigarettes do not produce traditional cigarette smoke. They had varied opinions about what to call regular users of e-cigarettes.

CONCLUSIONS

Findings highlight that conceptual clarity, including using specific and familiar terminology and product descriptions for users and nonusers alike, is challenging and crucial. It is important that surveillance efforts, policy development, messaging, and future research reflect the language understood and used by consumers to enable widespread comprehension.

Tobacco denormalisation and representations of different tobacco users in Norway: a cross-sectional study

This study asks whether representations of different typical tobacco users vary in line with established stereotypes and by social group membership (especially tobacco user status). Social identity theory posits that representations differ due to varying identification with product users on the basis of personal use, while distinction theory suggests representations will be structured by proximity and distance to user groups. Using principal component analysis to identify representations and regression analysis to determine variances in representations, we find that four of five groups of typical tobacco users (snus users, pipe, cigarette, and cigar smokers) can be classified according to three similar representations: socially secure, culturally marginal and unappealing. Respondents who themselves use a certain tobacco product are more likely to consider a 'typical' user from their own group as more 'socially secure' and less 'culturally marginal' and 'unappealing' than non-users. Former smokers tend to side with non-smokers, which suggests their 'smoker identity' is on the wane. At the representational level, then, socio-historical distinctions between different tobacco products seem to have diminished in favour of a largely dual classification, with users expressing positive and non-users negative representations, of any typical user. This is a likely consequence of persistent tobacco denormalisation policies.

Exploring Smoking Stigma, Alternative Tobacco Product Use, & Quit Attempts

OBJECTIVES

Investigate smoking stigma among different tobacco user types.

METHODS

US adults (N=1,812) responded to an online survey, including non-smokers, smokeless tobacco users, exclusive smokers, and smokeless and cigarette "dual users".

RESULTS

Dual users perceived the highest smoking stigma. Stigma was higher for smokers open to quitting by switching to smokeless. E-cigarette users (smokers) reported higher stigma than non-users. Making a past-year quit attempt was predicted by smoking stigma, and smokeless and/or e-cigarette use.

CONCLUSIONS

Smoking stigma and dual use of smokeless tobacco and/or e-cigarettes with cigarettes predict quit attempts. However, smoking stigma might prevent smokers from consulting doctors and induce use of alternative tobacco products as cessation aids.

Tobacco Denormalization as a Public Health Strategy: Implications for Sexual and Gender Minorities

Although the population-level success of tobacco denormalization is widely accepted, it remains unclear whether these strategies alleviate health inequities for sexual and gender minorities. The high risk of smoking among sexual and gender minorities together with research that documents a relationship between stigma-related processes and smoking prevalence for these groups raises questions about whether tobacco-related stigma intensifies the disadvantages associated with the stigmas of other social identities. We have not adequately considered how tobacco-related stigma overlaps with other social identity stigmas. Given concerns about the intensification of inequality, this type of inquiry has important implications for understanding both the effectiveness and limitations of tobacco denormalization strategies for sexual and gender minorities and identifying those tobacco prevention, treatment, and public health policies that work to ameliorate health inequities.

Smoking Norms and the Regulation of E-Cigarettes

Electronic nicotine delivery systems (ENDS)-commonly called e-cigarettes-are at the center of a polarized debate. How should they be regulated? Central to this debate is the concern that e-cigarettes could lead to the renormalization of smoking and that the regulation of ENDS should therefore be modeled on the regulation of conventional cigarettes. I argue that arguments based on the renormalization of smoking can lend support to restrictions on marketing of ENDS, but that such arguments are problematic when used to justify restrictions on where ENDS can be used. The debate has been insufficiently sensitive to the ethical complexities of attempts to manipulate social norms to change health behaviors; these complexities must also inform the debate about ENDS and their regulation.

The downside of tobacco control? Smoking and self-stigma: A systematic review

OBJECTIVE

Little is known about the consequences of tobacco smoking stigma on smokers and how smokers may internalize smoking-related stigma. This review summarizes existing literature on tobacco smoking self-stigma, investigating to what extent smokers are aware of negative stereotypes, agree with them and apply them to themselves.

METHODS

We carried out a systematic search of Pubmed/Web of Science/PsycInfo databases for articles related to smoking self-stigma through June 2013. Reference lists and citations of included studies were also checked and experts were contacted. After screening articles for inclusion/exclusion criteria we performed a quality assessment and summarized findings according to the stages of self-stigma as conceptualized in Corrigan's progressive model of self-stigma (aware, agree, apply and harm). Initial searches yielded 570 articles.

RESULTS

Thirty of these articles (18 qualitative and 12 quantitative studies) met criteria for our review. Awareness of smoking stigma was virtually universal across studies. Coping strategies for smoking stigma and the degree to which individuals who smoke internalized this stigma varied both within and across studies. There was considerable variation in positive, negative, and non-significant consequences associated with smoking self-stigma. Limited evidence was found for subgroup differences in smoking-related stigma.

CONCLUSION

While there is some evidence that smoking self-stigma leads to reductions in smoking, this review also identified significant negative consequences of smoking self-stigma. Future research should assess the factors related to differences in how individuals respond to smoking stigma. Public health strategies which limit the stigmatization of smokers may be warranted.