Nicotine - Stigma

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Stigma and stigmatizing language lead to viewing people as less worthy and can lead to bias, racism, and discrimination. Stigma can affect the mental health of the stigmatized, may inhibit their ability to achieve wanted changes in their lives, and may cause them to avoid medical care or helpful services.

Smoking (Nicotine) Stigma and the use of "Smoker"

Videos

2021: E-Cigarette Summit: Stigma and tobacco harm reduction: what we can learn from other health behaviors

  • Prof Scott Leischow
  • Stigmatizing smoking has been at the heart of tobacco control efforts for decades, which may drive more people to quit but at the same time potentially create new difficulties for smokers, including self-isolation, creation of social groups that might become ‘hardened’ to changing smoking behaviors, and perceptions by the user and society that complete abstinence is the only option. The stigma associated with a wide variety of behaviors has impeded progress toward improving population health in some cases, such as the reticence in making products and services available that could reduce the risk of communicable disease (eg needle exchanges), as well as harm reduction products that could benefit users and society when an individual addicted to a substance is not able to or chooses not to become completely abstinent (eg NRT, ENDS, smokeless tobacco). This presentation will explore some of the conflicting aspects of stigma in tobacco control, explore similarities and differences regarding the stigma of using of different addicting substances, and consider some research, practice and policy directions.


Studies, Papers, Reports - Smoker

2022: Reducing stigma triggered by assessing smoking status among patients diagnosed with lung cancer: De-stigmatizing do and don't lessons learned from qualitative interviews

  • Patients expressed clear preferences for CCPS to refrain from using judgmental labels when assessing smoking history, including a preference for questions such as “have you smoked cigarettes in the past 30 days” rather than “are you a smoker?” . This perspective is consistent with the broader clinical efforts and dissemination of resources to reduce illness-related stigma through the increased use of person-first language and other bias-free language in clinical care and research.

2020: Changing the Language of How We Measure and Report Smoking Status: Implications for Reducing Stigma, Restoring Dignity, and Improving the Precision of Scientific Communication

  • However, the descriptors we commonly use to classify people who smoke may inadvertently perpetuate harmful, stigmatizing beliefs and negative stereotypes. In recognizing the power of words to either perpetuate or reduce stigma, Dr. Nora Volkow—Director of the National Institute on Drug Abuse—recently highlighted the role of stigma in addiction, and the movement encouraging the use of person-first language and eliminating the use of slang and idioms when describing addiction and the people whom it affects.
  • In this commentary, we make an appeal for researchers and clinicians to use person-first language (eg, “people who smoke”) rather than commonly used labels (eg, “smokers”) in written (eg, in scholarly reports) and verbal communication (eg, clinical case presentations) to promote greater respect and convey dignity for people who smoke. We assert that the use of precise and bias-free language to describe people who smoke has the potential to reduce smoking-related stigma and may enhance the precision of scientific communication. [emphasis added]


Studies, Papers, Reports - Smoking

2022: What low-income smokers have learned from public health pedagogy: A narrative inquiry

  • Frohlich et al and others have suggested that public health educational messages may have the unintended consequence of marginalizing low-income smokers and unintentionally contributing to health disparities. Our study participants also point to healthcare professionals as an important group who may be contributing to these feelings. With this in mind, efforts to educate healthcare providers on how their actions may be perceived as judgmental or lacking in compassion about the effects of nicotine withdrawal are warranted.

2020: Stigma and Smoking in the Home: Parents’ Accounts of Using Nicotine Replacement Therapy to Protect Their Children from Second-Hand Smoke

  • However, smoking prevalence remains disproportionally high in socioeconomically disadvantaged groups.
  • Smoking stigma, particularly self-stigma, underpinned accounts, with two overarching themes: interplaying barriers and enablers for creation of a smoke-free home...
  • 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.
  • Whilst denormalisation of smoking has been a useful public health tool for reducing smoking rates in the UK, it is arguable that this can lead to unhelpful stigmatisation of already vulnerable disadvantaged groups.

2019: DOES IT HELP SMOKERS IF WE STIGMATIZE THEM? A TEST OF THE STIGMA-INDUCED IDENTITY THREAT MODEL AMONG U.S. AND DANISH SMOKERS

  • Thus, stigmatization led smokers toward emotional, cognitive, and attitudinal reactions that might make them less likely to quit.

2017: Internalized smoking stigma in relation to quit intentions, quit attempts, and current e-cigarette use

  • Consistent with previous research we have found that smokers’ who reported greater feelings of stigmatization about their smoking were more likely to report having made recent quit attempts and report a stronger intention quit smoking in the future.
  • It is also important to recognize the potential negative consequences associated with stigmatizing smokers, who may seek ways to evade stigma by segregating themselves into groups accepting of smoking and perhaps fostering the development of fatalistic attitudes about their ability to change their smoking behavior, which make quitting smoking harder to accomplish. Thus, behavioral interventions for smoking cessation might include addressing stigma-related issues as part of the quitting process.

2015: Validity and Reliability of the Internalized Stigma of Smoking Inventory: An Exploration of Shame, Isolation, and Discrimination in Smokers with Mental Health Diagnoses

  • In addition to the health disparities experienced by smokers, psychosocial factors such as smoking stigma can cause additional strain on health, and may thwart positive behavior change. Smoking stigma can be defined as a social process by which exclusion, rejection, blame or devaluation occurs,7 in this case related to smoking or being identified as a smoker. Stigma can be categorized as: 1) internally-focused self-stigma resulting from the internalization of public stigma and characterized by statements about the individual's worth, e.g., “I am worth less because I smoke”; 2) perceived or felt stigma, which is an awareness of devaluation or stereotype in work, social, and everyday situations, and includes fear of being stigmatized, experiencing external blame, and social isolation; or 3) enacted stigma, which refers to acts of discrimination perpetrated on stigmatized individuals.
  • We would consider, however, efforts to induce stigma as abjectly wrong and avoidable. Instead, treatment engagement strategies could emphasize stigma-reduction as an ancillary benefit – i.e., messaging that quitting smoking can reduce stigma, rather than messaging aimed at increasing stigma to induce quitting.

2008: Tobacco control and the inequitable socio-economic distribution of smoking: smokers’ discourses and implications for tobacco control

  • Full Study on Sci-Hub
  • Few low SES smokers questioned their smoking status, instead framing smoking as a ‘fact of life’. However, there was also a clear sense that tobacco control, and its adherents, are contributing to a sense of stigmatised identity for these smokers.


Studies, Papers, Reports - Employment and Insurance

2018: A qualitative review of tobacco research related to public and structural stigma.

  • Our review found that some smokers experience self-stigma such as self-loathing and shame as a result of public stigma. The few studies on structural interventions suggest that they affect some smokers in counterproductive ways, such as eliciting defiance and/or prompting public and self-stigma.
  • Importantly, no studies examine stigma-related impact of newer structural interventions, such as higher insurance premiums or worksite policies to employ only nonsmokers.
  • To advance the field, it will be critical to pinpoint whether, when, and how denormalization becomes stigmatization. [emphasis added]
  • Removing the stigmatizing aspects of existing approaches, and creating new interventions that avoid stigmatizing smokers, may help further enhance the reach and effectiveness of tobacco control.

2016: Smoking Cessation and the Role of Stigma: A Systematic Review

  • What emerged from this review is current anti-smoking campaigns are not effective for smokers who are living in poverty. These findings suggest that anti-smoking campaigns need to limit stigma and build programs that are effective for all socio-economic classes.
  • Anti-smoking campaigns have been used for the last three decades, and while there has been a decrease in smokers across the US, the number of smokers living in poverty has remained relatively unchanged. The research points to the use of stigma as a possible reason for smokers who are living in poverty to not stop smoking. The use of stigma to help a population, who may be stigmatized for multiple reasons, has shown through the research, to be a poor tool in moving them towards a smoke free life. The use of stigma in public health campaigns may lead to making things worse for smokers who live in poverty through discrimination in hiring policies and other unintended consequences.

2015: The Downside of Tobacco Control? Smoking and Self-Stigma: A systematic review

  • While there is evidence that internalizing smoking stigma may prompt some individuals to quit smoking, this review also suggests that smoking self-stigma can have profoundly negative consequences for some smokers and may make quitting more difficult.
  • Currently, there may be an overreliance on strategies which focus on negative reinforcement including both strategies to change smoking norms and increase smoke-free public spaces as well as more structurally stigmatizing policies such as basing hiring decisions and health insurance costs on smoking status.

2008: Smoking and the emergence of a stigmatized social status

  • Structural forms of discrimination perpetrated against smokers and former smokers (e.g., company policies against hiring smokers) are also related to smoker-related stigma.


Articles, Websites, Blogs

2022: How to Reduce Mental Health Stigma, Smoking Stigma in the Workplace

  • It can be tempting to dismiss these kinds of negative labels as simply semantics, but research has shown that language matters. Using person-first language like “people who smoke” instead of “smokers” acknowledges the tenacity of this disease, conveys dignity and greater respect, and can reduce smoking-related stigma.
  • People who smoke are often perceived as having negative personality and social traits.
  • These aren’t silent biases either: these negative perceptions influence attitudes about people who smoke, which in turn influence non-smokers’ willingness to interact with people who smoke.
  • ...there are 21 states that do not offer employment protection to tobacco users, allowing employers to refuse to hire people who smoke. Unsurprisingly, people who smoke have a harder time getting hired. For example, the chances of getting a job within a year is reduced by 24% for unemployed job seekers who smoke compared to non-smokers, even when other factors like criminal history are considered.
  • And even with a job, the stigma still carries through, as people who smoke earn 20% less compared to non-smokers.
  • Stigma associated with many mental health conditions like depression is now a well-recognized issue. By acknowledging this stigma, it has allowed considerable progress to be made. Unfortunately, the same progress has not been made in reducing the stigma of substance use disorders like nicotine addiction.

2021: A New Guide Encourages the Use of Language that is Respectful of Patients, Free of Stigma, Inclusive, and Equitable

  • End stigma: Promote judgment-free, bias-free language. Try 'person who smokes' rather than 'smoker.' [emphasis added]
  • 'A person with nicotine dependence' instead of 'a nicotine addict.'


Examples of an alternative to "smoker" - PWS (People Who Smoke)

CDC - Centers for Disease Control and Prevention: Preferred Terms for Select Population Groups & Communities

  • Instead of this… "Smokers," Try this... "People who smoke"

2022: Smoking and social housing from LIN and ASH

  • "People who smoke" are mentioned 16 times in this report. One example: "These particular examples also shine a light on the potential of e-cigarettes for people who smoke and live in social housing. Reviews of the evidence by the National Academies of Sciences, Engineering and Medicines in the US and the UK Committee on Toxicity have concluded that the relative risk of adverse health effects from e-cigarettes are likely to be substantially lower than from smoking. E-cigarettes have also been shown to be an effective aid for quitting, in clinical trials and at population level, with some evidence suggesting they are even more effective than traditional forms of nicotine replacement therapy, like patches and gum. They also appear to have been particularly valuable among groups who face higher levels of addiction and more barriers to quitting, for example among people experiencing homelessness and people with mental health conditions. Considered alongside the evidence from the ‘Swap to-Stop scheme, e-cigarettes therefore present a real opportunity to substantially benefit people who smoke and live in social housing."

Health Canada

  • "Today, to mark World No Tobacco Day, the Honourable Patty Hajdu, Minister of Health, announced $3 million in funding for a national social marketing campaign to encourage people who smoke to quit."

American Cancer Society

  • "Some people who smoke choose to try e-cigarettes to help them stop smoking. Stopping smoking clearly has well-documented health benefits...People who have already switched completely from smoking to e-cigarettes should not switch back to smoking (either solely or along with e-cigarettes), which could expose them to potentially devastating health effects."


"Relapse"

  • Suggested words to use instead of relapse(d): recurrence (appears to be the most widely used), return, resume (resumption), slip, lapse, (use) episode, substance use (no strings attached to current, former, daily, random), revert, recent use... these and other suggestions can be found on this question posed on Twitter in the comments.

Articles, Websites, Blogs

2019: It’s Time to Quit Using… Stigmatized Words Like Relapse

  • Much of society associates the term “relapse” with failure because of an antiquated and baseless condemnation of individuals with substance use disorder who do not become “cured” with their first treatment. Very often, there is immediate judgment.
  • I propose that if we want to help erase stigma, we choose to use the word recurrence rather than relapse. “Recurrence of substance use disorder” creates a more accurate connotation, one that is more consistent in the medical world.
  • Our language activates implicit cognitive scripts that give meaning to what we try to convey and communicate.


"Black Words - Example: Black Market"

Studies, Papers, Reports

2018: “Blacklists” and “whitelists”: a salutary warning concerning the prevalence of racist language in discussions of predatory publishing

  • This commentary addresses the widespread use of racist language in discussions concerning predatory publishing. Examples include terminology such as blacklists, whitelists, and black sheep. The use of such terms does not merely reflect a racist culture, but also serves to legitimize and perpetuate it.
  • The racism in such “black is bad, white is good” metaphors is inappropriate and needs to cease.
  • ...the word WHITENESS has 134 synonyms; 44 of which are favorable and pleasing to contemplate…Only ten synonyms for WHITENESS appear to me have negative implications—and these only in the mildest sense… The word BLACKNESS has 120 synonyms, 60 of which are distinctly unfavorable, and none of them even mildly positive…


Articles, Blogs, Websites

2021: Say This Instead: “Blacklist,” “Blackball,” “Blackmail,” “Black market,” etc.

  • "In a continuation of the “Say This Instead” series, let’s look at the pervasive symbolism of “white” as positive and “black” as negative in the English language. Words like “blackmail” (related to extortion), “blackball” (rejection), “blacklist” (banishment), and “black market” (illicitness) are so woven into the fabric of our language that we often don’t reflect on their racist overtones. The meaning of these phrases is always something undesirable. It perpetuates a systemic stigma caused by using the same terms that describe the color of our skin as a delineation between good and bad. Based on our use of these words, “black” is bad and “white” is good."


"ANTZ, Karen, Shill, etc."

  • Comment from Skip, the creator of this wiki page:
    • Those of us who believe there is a place in the world for alternative nicotine products have witnessed years of stigmatization for people's nicotine use. I encourage all of us to think twice about our own use of stigmatizing words, especially when directed at those we don't agree with. We must remember that we sometimes seem like "zealots" to them, too. Name-calling, disrespectful attitudes, and hurtful words will never open the dialogue between opposing viewpoints. Don't be a PANTZ (pro-alternative nicotine and tobacco zealot). #BeKind - millions of people are dying from smoking. It is one thing to be enthusiastic, it is another thing to be a rude troll. Show your mission's credibility by treating others respectfully, even if they've come across as rude. #TeachByExample

ANTZ

  • Anti Nicotine and Tobacco Zealots
  • A derogatory label applied to individuals and groups focused on eliminating all nicotine and tobacco products without taking the continuum of risk into consideration. Some of those individuals believe that all forms of nicotine are harmful, and society would experience improved public health without the use of nicotine. Some of those individuals are hyper-focused on concerns about youth initiating nicotine use and struggle to include concerns for anyone who smokes. Much of this debate is focused on e-cigarettes. A good discussion on the lack of balance is this paper: Balancing Consideration of the Risks and Benefits of E-Cigarettes

Karen

  • A pejorative term for a (most often white) woman (or rarely a man) perceived as entitled or demanding beyond the scope of what is reasonable.
  • Sometimes called "soccer moms."

Shill

  • A shill is someone who publicly helps or gives credibility to a person, company, industry, or organization without disclosing their close relationship or employment. In online discussion media, shills make posts expressing opinions that further interests of an organization in which they have a vested interest, such as a commercial vendor or special interest group, while posing as unrelated innocent parties.
  • Both sides of the debate tend to aim this slur (without proof) at people they disagree with. Often to accuse someone of working in the tobacco industry or accuse someone of having their pockets lined by a wealthy funder who pushes a specific agenda. It is an attempt to discredit another person.


Words Matter - Lessons Learned: Drugs, Alcohol, Race, Gender, Mental Health, Weight, etc.

Videos

Let's Break the Stigma

  • How are you doing? How are you really doing?


Studies, Papers, Reports

2022: Why language matters in alcohol research: Reducing stigma

  • The results of a separate manual search (n = 110) on the Wiley Online Database showed that approximately 30% of articles used the term "alcoholic" in a stigmatizing manner.
  • Stigmatizing language can perpetuate negative biases against people with alcohol use disorder. We encourage researchers to shift away from language that maintains discriminatory conceptions of alcohol use disorder. Reducing stigma has the potential to increase rates of treatment seeking and improve treatment outcomes for individuals with alcohol use disorder.

2021: Weight Bias and Stigma: Impact on Health

  • "Weight bias and stigma exist in a variety of realms in our society (media, education, employment, and health care), and unfortunately many view it as a socially acceptable form of discrimination. Patients with obesity often avoid scheduling appointments for health promotion visits and routine care due to perceived weight bias and stigma from their health care provider."

2021: Media framing of emergency departments: a call to action for nurses and other health care providers

  • "Two overarching themes were found. First, in ED-related media that portrays health care needs of people experiencing health and social inequities, messaging frequently perpetuates stigmatizing discourses..."

2020: A Primer to Reduce Substance Use Stigma in the Canadian Health System

  • Substance use stigma is prevalent throughout the health system and contributes to poorer quality of care and negative health outcomes.
  • Creating a stigma-free health system will require collaborative action and sustained commitment of key players across the health system.
  • Efforts to reduce substance use stigma within the health system must also acknowledge and address intersecting stigmas, including through initiatives not traditionally labelled as “anti-stigma interventions”.

2019: LANGUAGE MATTERS Using respectful language in relation to sexual health, substance use, STBBIs and intersecting sources of stigma

  • Words matter. Certain words can make people or groups feel excluded, and can also convey stereotypes, expectations or limitations based on a person’s identity...
  • Language changes. As societal values change over time, so does the language that is considered acceptable...
  • Mindset matters. Be open and empathetic, and encourage others to do the same...
  • Person first. Use ‘person first’ language: language that prioritizes someone’s identity and individuality above whatever other characteristic you might be describing...
  • Be inclusive. Try and use language that is as inclusive as possible to reflect the known or unknown diversity of your audience. For example, instead of using the terms husband or wife when unsure of the sexual orientation and/or marital status of who you are speaking with, use the term ‘partner.’ Similarly, when referring to a group of people, try ‘folks’ instead of ‘guys.’
  • Be specific. Use language that is consistent with how a person identifies and is comfortable for them...
  • Be critical. Before introducing or describing someone based on personal characteristics (such as race, gender identity, (dis)ability, use of substances, etc.), ask yourself whether it is relevant and necessary to do so...

2019: Biased labels: An experimental study of language and stigma among individuals in recovery and health professionals

  • Results provide further evidence that previously identified stigmatizing labels have the potential to influence medical care and medical practitioner perceptions of individuals with substance use disorders and should be avoided.

2018: Considerations for substance-use disorder language: cultivating a shift from 'addicts in recovery' to 'people who thrive'

  • "We consider the role language plays in the SUD treatment field and how the language and concepts the words convey keep individuals from growing through and past the SUD. We argue that a new understanding calls for a shift in language among providers of SUD care in which the culture of SUD treatment begins to emphasize 'thriving' rather than 'recovery' from SUDs."

2018: Substance use, recovery, and linguistics: The impact of word choice on explicit and implicit bias

  • The general public, treatment professionals, and healthcare professionals have been found to exhibit an explicit negative bias towards substance use and individuals with a substance use disorder (SUD).
  • Results support calls to cease use of the terms "addict", "alcoholic", "opioid addict", and "substance abuser". Additionally, it is suggested that "recurrence of use" and "pharmacotherapy" be used for their overall positive benefits. Both "medication-assisted recovery" and "long-term recovery" are positive terms and can be used when applicable without promoting stigma.

2013: Stigmatizing harm reduction through language: a case study into the use of "addict" and opposition to supervised injection sites in Canada

  • "The use of labels is one way stigma is perpetuated by eliciting the label's stereotyped narratives onto an individual or group. Within harm reduction discourse, the word "addict" can have detrimental effects on how the public perceives people experiencing addiction and their deservingness of pragmatic services. This article aims to draw attention to the inattention we give "addict" in language and explain how its routine use in society acts to perpetuate addiction stigma. Using the example of supervised injection site opposition in Canada, the use of "addict" is used as a way to understand how stigma through language works to impede the expansion of harm reduction initiatives."


Articles, Websites, Blogs

RESPECT TO CONNECT: UNDOING STIGMA

  • What Does Stigma Look Like?
    • Stigma limits a person’s ability to access services they need because they feel unworthy of receiving or requesting services.
    • Stigma creates barriers while receiving services by people feeling unwelcome or judged by program staff that offers services.

Stigmatizing Stigmas

  • "The foundation of most societal issues is rooted in hierarchies and ideologies. These two concepts are bound together by one term: stigma. Stigmas support hierarchies and give power to ideologies. Each level of any hierarchy is bound to be linked to a stigma, whether the stigma is about the people, their attitudes, mannerisms, professions, or other factors. Though often compared to their cousin, the stereotype, stigmas have much darker undertones."


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