Do You Smoke? Stigma, Shame and Blame as Unintended Consequences of Tobacco Control

Jamie S. Ostroff, PhD; Jamie L. Studts, PhD & the Cancer SIG

Behavioral medicine has played a seminal role in the development of multi-level behavior change interventions designed to reduce cancer risk. Most notably, comprehensive, multi-pronged population-level, tobacco control interventions have greatly reduced the appeal and acceptability of smoking, increased smoking cessation, reduced secondhand smoke exposure, and decreased the initiation of cigarette smoking among young people. Behavioral medicine expertise has greatly contributed to many of these tobacco control tools and there is indeed much to celebrate in terms of reducing the population burden of smoking. Although hard-hitting, anti-tobacco, public health campaigns highlighting the health consequences of smoking have undoubtedly helped reduce the health burden of smoking, there is growing recognition of the potential harms of these messages and how it has impacted how society views and treats individuals who have smoked.¹ Regardless of their smoking history, the overwhelming majority of patients diagnosed with lung cancer report experiencing stigma often triggered by the ubiquitous question (“Do/Did You Smoke?”) following disclosure of their lung cancer diagnosis to family, friends, co-workers or even healthcare clinicians.²

What is lung cancer stigma?

Lung cancer stigma is defined as the recognition and subsequent devaluation of someone based on their diagnosis of lung cancer. A conceptual model as well as patient-reported tools are available for the measurement of three important facets of lung cancer stigma ^{3, 4}: Perceived Stigma, the perception of negative appraisals and devaluation from others (what others think and say); Internalized Stigma, the internalization of these feelings by patients (feelings of shame, guilt, or self-blame); and Constrained Disclosure, avoidance or discomfort in talking about one’s lung cancer with others, usually out of anticipation or fear that one would be met with stigma.

Why does lung cancer stigma matter?

Recent innovations in early detection, treatment, and survivorship have transformed lung cancer care, and have led to improved outcomes for individuals who face high lung cancer risk or who have been diagnosed with lung cancer. However, lung cancer stigma impedes access to these innovations in care and adversely impacts each component of the lung cancer control continuum. ⁵ Specifically, lung cancer stigma impedes engagement with and utilization of:

• evidence-based tobacco prevention and treatment
• high quality lung cancer screening
• optimal diagnosis and treatment
• survivorship support and palliative care
• end-of-life and bereavement care

Lung cancer stigma adversely impacts psychological adaptation to cancer and has been associated with:

• Depressive symptoms
• Anxiety
• Poor quality of life

What are some potential strategies for reducing stigma associated with smoking and other stigmatized health risk behaviors?

• Words matter! Use person-first and other de-stigmatizing language to reduce microaggressions  
• Appreciate complexity of patient narrative and lived experience
• Consider gain-framed, empowering, and empathic health behavior change messages
• Consider systemic factors that exacerbate lung cancer stigma – discrimination, medical mistrust, implicit bias, intersectionality
• Make empathic communication skills a core competency for all health care trainees and practitioners ⁶
• Promote partnerships with patients, advocates and marginalized communities
• Measure stigma as a potential target for psychosocial interventions 

• Develop and test multi-level (patient, clinician and societal) anti-stigma interventions on psychosocial patient outcomes, cancer care delivery, and health policy
• Become involved with the National Lung Cancer Roundtable's Lung Cancer Stigma Initiative and confront lung cancer stigma on the societal level

In summary, health behavior change need not have adverse psychosocial consequences. As behavioral medicine researchers, clinicians, and educators, it is imperative for us to develop, evaluate, and disseminate inclusive and equitable health behavior change interventions that promote health lifestyles and maintain dignity, compassion and respect for individuals struggling with behavior change. No Shame, No Blame!