An online pre-publication article just released in the American Journal of Public Health asks tobacco control and public health practitioners to reconsider the use of stigmatization of smokers as a strategy to reduce tobacco use (see: Bayer R, Stuber J. Tobacco control, stigma and public health: Rethinking the relations).
The article notes that strategies used to combat tobacco use have, in some cases intentionally, stigmatized smokers in an effort to try to reduce smoking rates. For example: "The advocacy group Americans for Non-Smokers' Rights noted that tobacco control advocates had stumbled onto the best strategy for reducing tobacco consumption, 'encouraging society to view tobacco use as an undesirable and antisocial behavior.'"
Another example provided by Bayer and Stuber is the discriminatory and intrusive employment policies that have been discussed in recent days in The Rest of the Story: "Firms boldly announce that they will not employ and may even fire smokers because of the additional cost of their medical care, or because smoking does not project the 'image' they wish to present to the public."
For perhaps the first time in a major public health journal, these authors are questioning, on an ethical as well as utilitarian basis, whether the stigmatization of smokers is justified in public health. They note that efforts to reduce smoking by stigmatizing smokers "run counter to a revisionist orthodoxy that had emerged during the last years of the 20th century that asserts that stigmatization of those who are already vulnerable provides the context within which disease spreads, exacerbating morbidity and mortality by erecting barriers between caregivers, and those who are sick, and by imposing obstacles on those who would intervene to contain the spread of illness. In this view, it is the responsibility of public health officials to counteract stigmatization if they are to fulfill the mission to protect the communal health."
The authors note that the tendency of the tobacco control movement to "ignore without comment the overarching concerns raised in prior years about the relation between stigmatization and effective public health interventions. ... the moral question of how to balance the overall public health benefit that may be achieved by stigmatization against the suffering experienced by those who are tainted by 'spoiled identities' is virtually never addressed."
The authors suggest that the answer to this balancing question may lie with a careful analysis of "the nature and extent of stigma-associated burdens and on how the antitobacco movement deploys stigmatization as an instrument of social control. For example, policies and cultural standards that result in isolation and severe embarrassment are different from those that cause discomfort. Those that provoke a sense of social disease are not the same as those that mortify. Acts that seek to limit the contexts in which smoking is permitted are different from those that restrict the right to work, to access health or life insurance, or to reside in communities of one's choice."
The Rest of the Story
In many ways, this concerns expressed by the authors of this article are the kind of concerns that I have developed over the past few years and are precisely the type of concerns that led to the development of this blog.
For at least some of us working in tobacco control and public health, the balance between changing social norms regarding smoking to discourage tobacco use and stigmatizing smokers and causing undue interference with the dignity of their lives has swung during recent months and years, to the point that we now question whether the net impact of current policies being pursued may actually be to increase the burden that we are imposing on a socially vulnerable population, and ultimately, having a negative impact on the public's health.
For raising these concerns, I have been banished from a tobacco control network, but it is good to see that the major public health journal is still a forum in which concerned practitioners can express their opinions and attempt to stimulate a much-needed discussion among public health, and hopefully, tobacco control practitioners.
And this blog will remain a highly visible venue which will continue to bring this issue to the attention of the tobacco control community.
I have opined that the tobacco control movement has crossed the line from interventions to change social norms to support nonsmoking and therefore decrease cigarette use to policies that directly stigmatize smokers, interfere unduly with their lives, and violate core public health principles. The actions of organizations such as Americans for Nonsmokers' Rights to attack and vilify individual smokers and smokers' groups, to attempt to malign the character of individuals with any affiliation with a tobacco company, and to create an environment in which the individual smoking advocate, rather than the tobacco industry itself, is the enemy, are perfect examples of this.
So are policies that use smokers as a source of tax revenue to balance state budgets, that make smoking a condition of employment, and that ban smoking widely in open, non-enclosed outdoors places.
I am concerned because of the lack of response I have received from the tobacco control community. If it seemed that any substantial fraction of that community was truly concerned and interested in discussing this issue, I would feel reassured. However, the lack of interest in discussion that might, in some way, interfere with the professed agenda of the movement scares me.
And it suggests that without intervention, the balance is not going to swing back to the side of appropriately protecting the public's health.
Specific ads from recent anti-smoking media campaigns and statements by tobacco control leaders illustrate this, as pointed out by Audrey Silk in her letter to Judge Gladys Kessler (who is hearing the Department of Justice's lawsuit against the tobacco companies) on behalf of N.Y.C. CLASH.
For example, one ad from the California and Massachusetts Departments of Health, was apparently described as follows: "One of the television ads ...features a cartoon character, a smoker, who laments with Woody-Allen-like angst that he can't quit. 'Ah, he says, it's no use. I'm scum. I've always been scum.'"
The text of another ad apparently stated: "A gas chamber is a chamber filled with poisonous gas. If you're with someone who's smoking, you're in one right now."
The deputy director for prevention services in California was quoted as stating: "Our idea is to make California a hostile environment for smoking."
And a former Surgeon General was quoted as stating: "If somebody had told me that smoking would become an anathema and smokers would become pariahs, I would have said it would take two generations to accomplish that. It's happened in 25 years, so I guess we did it in a single generation."
When smokers are called "scum," when being with a smoker is called being in a "gas chamber," when public health practitioners want to create a "hostile" environment for smokers, and when the goal of the movement is to make smokers "pariahs," then I think you have to stop and think that maybe something is wrong. Maybe things have gone astray.
The rest of the story is that things have gone badly astray in the tobacco control movement. By bringing this issue to public attention, Bayer and Stuber have done a great service, I believe. And The Rest of the Story will continue to bring the deviation of the tobacco control movement from the public health path to public attention, despite efforts from within the tobacco control movement to stop me from telling the story that needs to be told.