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

Racism, discrimination, medical mistrust, stigma, and lung cancer screening: a scoping review

OBJECTIVE

Lung cancer screening can reduce lung cancer-specific mortality, but it is widely underutilized, especially among minoritized populations that bear a disproportionate burden of lung cancer, such as Black Americans. Racism, discrimination, medical mistrust, and stigma contribute to lower uptake of preventive screenings in general, but the role these factors play in lung cancer screening is unclear. We therefore conducted a scoping review to synthesize the literature regarding how racism, discrimination, medical mistrust, and stigma relate to lung cancer screening.

DESIGN

Informed by PRISMA-ScR guidelines, we searched five databases for relevant literature, and two trained researchers independently reviewed articles for relevance. We conducted a narrative, descriptive analysis of included articles.

RESULTS

A total of 45 studies met our inclusion criteria. Most articles reported on medical mistrust or one of its cognates (e.g. trust and distrust, n = 37) and/or stigma (n = 25), with several articles focusing on multiple constructs. Few articles reported on racism (n = 3), and n = 1 article reported on discrimination. Results from empirical studies suggest that medical mistrust, distrust, and stigma may be barriers to lung cancer screening, whereas trust in health care providers may facilitate screening. The articles reporting on racism were commentaries calling attention to the impact of racism on lung cancer screening in Black populations.

CONCLUSIONS

Overall, novel interventions are needed to promote trust and reduce mistrust, distrust, and stigma in lung cancer screening initiatives. Dedicated efforts are especially needed to understand and address the roles that racism and discrimination may play in lung cancer screening.

Examining socio-economic disparities among e-cigarette users and cigarette smokers in three Canadian jurisdictions

INTRODUCTION

It is well established that a gradient exists among cigarette smokers, such that smoking is more prevalent among individuals who are of lower socio-economic status (SES). In this study, we examined whether a similar SES gradient exists among electronic cigarette (e-cigarette) using youth and adults in three Canadian jurisdictions.

METHODS

A secondary analysis of data from Ontario, Quebec and Yukon respondents (n = 58,592) to the 2017-2018 Canadian Community Health Survey was conducted. Unadjusted and adjusted logistic regression models explored SES measures: total and relative household income, and education level, separately on use of e-cigarettes or cigarettes in the past 30 days. Models adjusted for additional socio-demographic and psychosocial covariates.

RESULTS

A significant inverse SES gradient existed for cigarette smoking based on education and income variables, with higher education and income associated with decreasing consumption in a stepwise manner. No SES gradient was observed for e-cigarettes.

DISCUSSION AND CONCLUSIONS

While a robust SES gradient was observed among cigarette smokers, no gradient for e-cigarette use was observed. Explanations for these findings may be linked to perceptions that e-cigarettes are healthier, have convenient designs and appealing flavours, and less stigmatised. As more becomes known about potential harms from e-cigarettes, effective interventions may be needed to prevent the emergence of a gradient that disproportionately affects those at lowest income and education levels. Continued monitoring of e-cigarette use patterns across SES groups is necessary for public health.

Lived experiences of stigma and altered self-perceptions among young people who are addicted to ENDS: a qualitative study from Aotearoa New Zealand

INTRODUCTION

Rising use of electronic nicotine delivery system (ENDS) among young people, especially those who have never smoked, has received considerable attention from the health community. However, fewer studies have examined the mental health impacts of ENDS use. We addressed this gap by exploring the stigma, altered self-perceptions and negative affect experienced by adolescents who assessed themselves as addicted to using ENDS.

METHODS

We interviewed 20 adolescents aged 16-18 who lived in Aotearoa New Zealand and assessed themselves as moderately or highly addicted to ENDS use. Using in-depth, semistructured qualitative interviews, we explored participants' experiences of addiction and its effects on their well-being. We interpreted the data using an inductive reflexive thematic analysis approach.

RESULTS

We identified four key themes. First, addiction to ENDS use adversely affected participants' physical and mental health. Second, addiction greatly diminished the pleasurable effects ENDS use first provided and participants who initially enjoyed using ENDS now felt unable to stop. Third, participants felt judged, stigmatised and belittled by others who did not understand their struggle with addiction. Fourth, they experienced several negative emotions, including self-blame, regret, disappointment and embarrassment that diminished how they saw themselves.

CONCLUSIONS

We extend earlier studies by probing the mental health burden ENDS use imposes on young people, offer new insights into how they experience addiction and outline potential policy responses. Measures reducing young people's access to ENDS are urgently needed alongside empathetic, youth-oriented cessation support.

Optimising messages and images for e-cigarette warnings

BACKGROUND

The US Food and Drug Administration (FDA) requires electronic cigarettes (e-cigarettes) to have a single addiction warning, but many other health harms are associated with vaping and warnings grow stale over time. We aimed to develop new warning messages and images to discourage e-cigarette use.

METHODS

Participants were 1629 US adults who vaped or smoked. We randomised each participant to evaluate 7 of 28 messages on newly developed warning themes (metals exposure, DNA mutation, cardiovascular problems, chemical exposure, lung damage, impaired immunity, addiction), and the current FDA-required warning (total of 8 messages). Then, participants evaluated images of hazards (eg, metal), internal harms (eg, organ damage) or people experiencing harms.

RESULTS

Regarding intended effects, new warning themes all discouraged vaping more than the current FDA-required warning (all p<0.001), led to greater negative affect (all p<0.001) and led to more anticipated social interactions (all p<0.001). The most discouraging warnings were about toxic metals exposure. Regarding unintended effects, the new themes led to more stigma against people who vape (6 of 7 themes, p<0.001) and led to a greater likelihood of thinking vaping is more harmful than smoking (all 7 themes, p<0.001), although unintended effects were smaller than intended effects. Images of harms (internal or people experiencing) discouraged vaping more than images of hazards (all p<0.001).

DISCUSSION

Vaping warning policies should communicate a broader range of hazards and harms, beyond addiction, to potentially increase awareness of health harms. Images of internal harm or people experiencing harms may be particularly effective at discouraging vaping.

Smoking Discrimination Moderates the Relationship between Smoking Stigma and Cigarettes Per Day among Sexual and Gender Minority Individuals

Background: Sexual and gender minority (SGM) individuals report rates of tobacco use that range from 19% to 40% compared to roughly 20% of the general population. Higher rates of tobacco use, compounded by stress from discrimination, contribute to lower cessation rates and worse smoking-related outcomes for SGM individuals. Having multiple stigmatized identities, such as identifying as SGM and being a person who uses cigarettes, may further increase smoking, and decrease the likelihood of cessation. Smoking-related stigma is one relatively unexplored factor that may be related to smoking frequency. Objectives: The present study sought to examine how smoking stigma was related to smoking frequency, and how discrmination moderates the relationship between smoking stigma and cigarettes per day. Results: A sample of 399 self-identified SGM individuals (Mage = 36.69) was collected via Qualtrics Panels. Participants were primarily White and bisexual. Participants completed a battery of questions, including measures regarding smoking frequency (operationalized in this article as cigarettes per day [CPD]), smoking felt-stigma, smoking self-stigma, and smoking discrimination. Moderation analyses revealed significant interactions of felt- and self-stigma with smoking-related discrimination. For individuals who perceived higher levels of both self- and felt-stigma, experiencing increased smoking discrimination was associated with increased smoking frequency. However, there was no significant interaction with discrimination for individuals who had lower levels of felt- and self-stigma. Results have implications for smoking reduction and cessation. Helping individuals who have higher levels of felt- and self-stigma manage stress related to being stigmatized may motivate individuals to reduce smoking. Ultimately, these findings can play a role in crafting smoking reduction and cessation programs targeted toward SGM communities, particularly individuals who experience high levels of smoking-related stigma.

The Effect of Stigmatization on Diabetes Health Promotion Self-Care Behaviours and Predictors of Stigma and Self-Care Behaviours in Individuals With Type 2 Diabetes

BACKGROUND

Individuals with type 2 diabetes are at risk of delaying or not performing diabetes health promotion self-care behaviours because of their social or self-stigmatization.

AIM

The study aimed to reveal the effect of stigmatization on diabetes health promotion self-care behaviours and predictors of stigma and diabetes health promotion self-care behaviours in individuals with type 2 diabetes.

METHODS

This cross-sectional study included 235 individuals with type 2 diabetes. The Diabetes Stigma Assessment Scale (DSAS) and Diabetes Health Promotion Self-Care Scale (DHPSCS) were used for data collection.

RESULTS

There was a significant, negative correlation between the DSAS and DHPSCS scores. High mean scores on the DSAS and its subscales treated differently, blame/judgement and self-stigma were predictors of a negative effect on diabetes self-care behaviours. Poor health status, alcohol intake and diabetes complications are predictive of stigma. Insulin use and self-monitoring blood glucose are predictors of self-care behaviours.

CONCLUSION

Stigma negatively affects diabetes self-care behaviours in individuals with type 2 diabetes. Nurses could provide education on improvement of health status, harms of alcohol intake and management of diabetes complications. Counselling for coping with stigma and performing self-care could be provided. Nurses could organize interventions to raise awareness about diabetes in society.

Intention to quit or reduce e-cigarettes, cannabis, and their co-use among a school-based sample of adolescents

INTRODUCTION

Little is known about the prevalence and predictors of adolescents' intention to quit or reduce use of e-cigarettes and/or cannabis.

METHODS

Frequencies of intention to change (quit, reduce) e-cigarettes and/or cannabis use were examined among 23,915 surveyed middle and high school students with sole and co-use. Predictors of intention to change were identified via LASSO/multilevel logistic regression.

RESULTS

Among those with sole e-cigarette use (n = 543), 40.9 % intended to quit and 24.1 % intended to reduce; non-daily e-cigarette use predicted intention to quit and reduce e-cigarettes (p's < 0.03). Among those with sole cannabis use (n = 546), 10.6 % intended to quit and 25.1 % intended to reduce; absence of cannabis cravings predicted intention to reduce cannabis use (p < 0.01). Among those with co-use (n = 816), 26.2 % intended to either quit or reduce (quit/reduce) both substances, 27.5 % intended to quit/reduce e-cigarettes only, and 6.9 % intended to quit/reduce cannabis only. No predictors emerged for intention to change e-cigarette use among those with co-use (p's > 0.09), but younger age, lack of poly-tobacco use, and lack of cannabis craving predicted intention to quit/reduce cannabis use (p's < 0.04).

CONCLUSIONS

More than half of adolescents with past-month e-cigarette use, regardless of concurrent cannabis use, expressed interest in changing their use. However, only heaviness of e-cigarette use emerged as a predictor of intention to change suggesting. While fewer students expressed interest in changing their cannabis use, cannabis cravings and poly-tobacco use predicted intent to change. Overall, findings emphasize the need to tailor interventions towards adolescents engaging in more problematic substance use patterns.

Knowledge and beliefs about lung cancer screening among Black individuals at high risk: a qualitative approach

Background

Despite its efficacy in reducing lung cancer (LC)-specific mortality by 20%, screening with low-dose computed tomography (LDCT) in eligible groups remains low (5-16%). Black individuals are more commonly affected by LC than other racial/ethnic groups in the United States (U.S.) but less likely to undergo LC screening (LCS). Our study aimed to explore the knowledge and beliefs of Black individuals at high risk regarding LCS.

Methods

Black individuals (n=17) who met the 2021 United States Preventive Services Task Force (USPSTF) LCS eligibility criteria were recruited in upstate New York. In-depth semi-structured interviews were conducted, audio recorded, and transcribed to explore knowledge and beliefs that could influence the uptake of LCS. A qualitative thematic analysis method was used to identify and analyze themes within the data.

Results

We identified principal themes about LC and LCS. Although most participants reported that smoking was the major risk factor for LC, some participants placed more emphasis on other factors as the major risk factors for LC and de-emphasized the role of smoking. Most participants were not aware that screening for LC existed. Several barriers and facilitators for LCS were identified.

Conclusions

Awareness about LCS among Black individuals is low. Addressing barriers may help increase LCS rates among Black individuals, ultimately reducing their LC mortality. The findings from our study have important implications in designing more effective interventions involving community health workers and healthcare clinicians to increase LCS uptake among Black individuals at high risk.

How do family members influence smokeless tobacco consumption during pregnancy in India? Perspectives of pregnant women

Smokeless tobacco (ST) use in South Asia is culturally ingrained and socially accepted. A better understanding of these sociocultural influences could inform behavioural approaches to prevent ST use. We sought to understand how family members influence pregnant women's behaviour, attitudes, and perceptions towards ST use. Moreover, we captured the influence of community health workers in this context. A qualitative study using a framework analysis was conducted in selected Indian populations. Eight in-depth interviews among pregnant and postpartum women were conducted in Gujarati, the local language, investigating ST use during pregnancy and the influence of family and peers. All transcripts were transcribed verbatim and translated into English and analyzed in NVivo. The social norms and expectations around ST during pregnancy appeared to have shifted away from promoting towards discouraging its use in the past few years. Women described how their spouses and other family members encouraged them to stop using ST during pregnancy, with some women must hide their ST use from their family members. They also received advice on the harms of ST use from community health workers (Accredited Social Health Activist-ASHA workers). Influenced by the advice received from such workers, several women tried to reduce their ST use during pregnancy. Our findings suggest that the acceptability of ST use in pregnancy may be in decline among families in India. Hence, efforts to promote ST prevention during pregnancy are likely to be "pushing against an open door". Furthermore, community health workers appeared to play an influential role in supporting women to abstain from ST use during pregnancy.

Discrimination and social identity processes predict impairment and dysfunction among heavy drinkers

BACKGROUND

Previous research has linked discrimination to poorer health. Yet health risk behaviours such as heavy alcohol consumption are often targeted with stigmatising public health campaigns. The current study sought to establish the link between experiencing discrimination and health outcomes among heavy drinkers, with a focus on exploring the multiple social identity processes that might underpin this relationship.

METHODS

A survey was conducted with 282 people who self-reported consuming alcohol above recommended guidelines. We measured discrimination experienced as a drinker, components of social identification as a drinker (centrality, satisfaction, solidarity, homogeneity, and self-stereotyping), and two health outcomes: psychological distress and severity of alcohol use disorder symptomatology.

RESULTS

Discrimination was a moderate-large predictor of psychological distress and alcohol use disorder symptoms. Three social identity constructs were implicated in the link between discrimination and ill-health: identity centrality and homogeneity positively mediated this relationship while identity satisfaction was a negative mediator. The model explained a large proportion of the variance (39-47%) in health outcomes.

DISCUSSION

Results are interpreted with an emphasis on the need to avoid stigmatising messaging and to prioritise social identity processes to prevent and treat substance use disorders. We further highlight the need for social identity researchers to consider the multidimensional nature of social identities, especially in the context of stigmatised groups.

Do school-based smoking preventive interventions have unintended effects? Post hoc analysis of the Focus cluster randomised controlled trial

OBJECTIVES

Public health interventions are designed to improve specific health-related outcomes; however, they may also produce negative side effects, such as substitution use, psychological or social harms. Knowledge about the unintended effects of school-based smoking preventive interventions is sparse. Hence, this study examined these potential unintended effects of the smoking-reducing intervention, Focus, among students in the vocational education and training setting.

DESIGN

Cluster randomised controlled trial stratified by school type with 5 months follow-up.

SETTING AND PARTICIPANTS

Across Denmark, eight schools were randomised to the intervention group (n=844 students, response proportion 76%) and six schools to the control group (n=815 students, response proportion 75%). This study focused solely on students who smoked at baseline (N=491).

INTERVENTIONS

The intervention was developed systematically based on theory and a thoroughly mixed-methods needs assessment. Intervention components included a comprehensive school tobacco policy (smoke-free school hours) supported by a 3-day course for school staff and launched by an edutainment session for students; class-based lessons and a quit-and-win competition; and individual telephone smoking cessation support.

OUTCOMES

Alternative tobacco and nicotine products (regular use of smokeless tobacco, hookah and e-cigarettes), regular cannabis use, boredom and loneliness at school, stress and perceived stigmatisation among smokers.

RESULTS

We found no statistically significant unintended effects of the intervention. Nonetheless, insignificant findings indicated that students in the intervention group were less likely to be bored during school hours (OR 0.59, 95% CI 0.32 to 1.10) and experience stress (OR 0.62, 95% CI 0.35 to 1.10), but more likely to report feeling stigmatised compared with the control group (OR 1.55, 95% CI 0.71 to 3.40).

CONCLUSIONS

Overall, findings suggested no unintended effects of the Focus trial with respect to substitution use, psychological, nor group or social harms. Future research is encouraged to report potential harmful outcomes of smoking preventive interventions, and interventions should be aware of the possible stigmatisation of smokers.

TRIAL REGISTRATION NUMBER

ISRCTN16455577.

Qualitative reactions to a low nicotine product standard for cigarettes from adolescents and young adults living in the United States who smoke

The Biden Administration is considering a low nicotine product standard for cigarettes. This qualitative study examined reactions to a nicotine reduction policy among adolescents and young adults (AYA) who smoke cigarettes. After completing a lab study involving masked exposure either to low nicotine or normal nicotine research cigarettes and unmasked exposure to e-cigarettes varying in nicotine concentration and flavor, we conducted follow-up semi-structured interviews (N = 25) to explore participants' knowledge, attitudes, and perceptions of a low nicotine product standard and their anticipated tobacco use behavior after policy implementation. Interviews were audio-recorded, transcribed verbatim, double-coded, and analyzed using reflexive thematic analysis. Nearly half of participants supported the policy because they thought it would prevent young people from starting smoking and/or would help people quit. Reasons some participants opposed the policy included beliefs that adults should have the choice to smoke or that a nicotine reduction policy is counterintuitive because the government benefits from cigarette sales. Others believed the policy would be ineffective because youth could circumvent the policy (e.g., illicit market) or would increase their smoking to maintain the same nicotine level. Almost half of participants said they would quit smoking while the other half said they would continue smoking, although potentially reduce their smoking. Overall, our qualitative findings point to the need for pre-policy media campaigns targeting AYA who smoke to minimize negative reactions, dispel fears, and correct misperceptions as well as encourage quitting and provide information on accessing cessation resources.

Tabac et précarité : l’enjeu central de l’accès aux soins

The prevalence and severity of smoking are particularly high in populations in precarious situations and make smoking an essential determinant of social inequalities in health, due to its particularly catastrophic impact on the health of these populations. The general reduction in smoking, less significant in disadvantaged populations, contributes to further increasing these inequalities, and smoking tends to be concentrated in the most vulnerable populations. The relationships between tobacco and precariousness are examined by identifying, based on a review of the literature, the main common factors of vulnerability: stress and social adversity, self-stigma, a low feeling of self-efficacy, the social function of tobacco use, the ambivalence of demands, associated addictions, the severity of tobacco dependence, distance from support and care systems, etc. Specific attention is paid to certain particular conditions: mental health disorders, addictions (other than tobacco), inadequate housing, detention, migration. On this basis, courses of action are proposed to improve access to care and its effectiveness for the people concerned. Emphasis is placed on the mobilization of professionals who often tend to neglect issues of smoking in view of the immediate severity of the problems at the origin of the demands of the people received. A support offer for harm reduction (vaping in particular) seems particularly suited to often-ambivalent demands. The importance of networking and the involvement of CSAPAs/CAARUDs is also underlined. At the systemic level, all of this must be accompanied by political advocacy to reduce these inequalities and social determinants of health..

California's tobacco 21 minimum sales age law and adolescents' tobacco and nicotine use: differential associations among racial and ethnic groups

OBJECTIVE

A California, USA, law raised the minimum tobacco sales age to 21 (T21) on 9 June 2016. We investigated whether T21 was associated with reductions adolescents' use of tobacco cigarettes, smokeless tobacco and electronic cigarettes and whether these associations differed across racial and ethnic groups.

METHODS

Secondary analyses of data from 2 956 054 7th, 9th and 11th grade students who participated in the California Healthy Kids Survey from 2010-11 to 2017-2018.

RESULTS

Multilevel mixed effects logistic regression analyses showed that T21 was associated with reduced prevalence of lifetime smokeless tobacco and e-cigarette use and past month smokeless tobacco use in the overall student population. T21 was associated with increases in prevalence of past month e-cigarette use. Moderation analyses indicated differences by racial and ethnic groups. Notably, T21 was associated with reductions in lifetime and past 30-day use of all tobacco and nicotine products among Latinx youth. The findings were more mixed for other racial and ethnic groups. Slopes analyses indicated that T21 was associated with accelerated downward trends for 30-day cigarette and smokeless use; moderated trends for lifetime cigarette smoking such that downward slopes became less steep; and reversed downward trends for e-cigarette use. Changes in slopes varied across racial and ethnic groups.

CONCLUSIONS

Our findings highlight the importance of understanding the complex associations that T21 and other tobacco control policies have with the use of different tobacco and nicotine products among racial and ethnic groups. Future research should investigate mechanisms underlying these differences to inform tobacco control efforts.

Ending the Pandemic: How Behavioural Science Can Help Optimize Global COVID-19 Vaccine Uptake

Governments, public health officials and pharmaceutical companies have all mobilized resources to address the COVID-19 pandemic. Lockdowns, social distancing, and personal protective behaviours have been helpful but have shut down economies and disrupted normal activities. Vaccinations protect populations from COVID-19 and allow a return to pre-pandemic ways of living. However, vaccine development, distribution and promotion have not been sufficient to ensure maximum vaccine uptake. Vaccination is an individual choice and requires acceptance of the need to be vaccinated in light of any risks. This paper presents a behavioural sciences framework to promote vaccine acceptance by addressing the complex and ever evolving landscape of COVID-19. Effective promotion of vaccine uptake requires understanding the context-specific barriers to acceptance. We present the AACTT framework (Action, Actor, Context, Target, Time) to identify the action needed to be taken, the person needed to act, the context for the action, as well as the target of the action within a timeframe. Once identified a model for identifying and overcoming barriers, called COM-B (Capability, Opportunity and Motivation lead to Behaviour), is presented. This analysis identifies issues associated with capability, opportunity and motivation to act. These frameworks can be used to facilitate action that is fluid and involves policy makers, organisational leaders as well as citizens and families.

Programme theory and realist evaluation of the 'Smoke-Free Vocational Schools' research and intervention project: a study protocol

INTRODUCTION

Smoke-free school hours (SFSHs) entails a smoking ban during school hours and might be an effective intervention to reduce the high smoking prevalence in vocational schools. For SFSH to be effective, the policy must be adequately implemented and enforced; this challenge for schools constitutes a research gap. The 'Smoke-Free Vocational Schools' research and intervention project has been developed to facilitate schools' implementation of SFSH. It is scheduled to run from 2018 to 2022, with SFSH being implemented in 11 Danish vocational schools. This study protocol describes the intervention project and evaluation design of the research and intervention project.

METHODS AND ANALYSIS

The intervention project aims to develop an evidence-based model for implementing SFSH in vocational schools and similar settings. The project is developed in a collaboration between research and practice. Two public health NGOs are responsible for delivering the intervention activities in schools, while the research partner evaluates what works, for whom, and under what circumstances. The intervention lasts one year per school, targeting different socioecological levels. During the first 6 months, activities are delivered to stimulate organisational readiness to implement SFSH. Then, SFSH is established, and during the next 6 months, activities are delivered to stimulate implementation of SFSH into routine practice. The epistemological foundation is realistic evaluation. The evaluation focuses on both implementation and outcomes. Process evaluation will determine the level of implementation and explore what hinders or enables SFSH becoming part of routine practice using qualitative and quantitative methods. Outcomes evaluation will quantitively assess the intervention's effectiveness, with the primary outcome measure being changes in smoking during school hours.

ETHICS AND DISSEMINATION

Informed consent will be obtained from study participants according to the General Data Protection Regulation (GDPR) and Danish data protection law. The study adheres to Danish ethics procedures. Study findings will be disseminated at conferences and further published in open-access peer-reviewed journals.

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.

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.

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.