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Smoking in a Non-Smoking Environment Smoking in a non-smoking environment: Inequality, stigmatization and resistance Marianne Lund Norwegian Institute for Alcohol and Drug Research incorporated into Norwegian Institute of Public Health from 01.01.2016 Dissertation submitted for the PhD degree Department of Sociology and Human Geography, University of Oslo March 2016 ©Marianne Lund, 2016 Series of dissertations submitted to the Faculty of Social Sciences, University of Oslo No. 603 ISSN 1564-3991 All rights reserved. No part of this publication may be reproduced or transmitted, in any form or by any means, without permission. Cover: Hanne Baadsgaard Utigard. Print production: Reprosentralen, University of Oslo. “In a culture where rationality and self-control are supremely valued, a person who affirms that he cannot control himself loses face and is ridiculed. However, a person who intends to exert control, but cannot despite his best ‘will power’, is admired and excused for his failing. One is only condemned if on does not try.” (Stein, 1985). Acknowledgements: First, I would like to acknowledge the support of my supervisor, Karl Erik Lund, for guidance in writing this thesis and the associated articles. Your wealth of knowledge about tobacco research and ability to actualize, problematize and challenge established mindsets is an inspiration for further work in the field of tobacco research. I would also like to thank Aksel Tjora for willingness to step into the project in a late phase with supportive and insightful comments. In addition, I would like to thank all of my colleagues at the former Norwegian Institute for Alcohol and Drug Research, SIRUS, which is the institution where almost all of the work for this thesis took place. I am grateful for the opportunity and financial support given by SIRUS to write this thesis. Special thanks go to the tobacco research group, to Gunnar Sæbø and Elisabeth Kvaavik for good discussions and support, and to Tord Finne Vedøy for help with STATA. Thanks to all of my supportive family and friends! Finally, my dear Ole Trygve, thanks for all support, your incredible patience and valuable comments during this process. Thanks Emma and Jenny, for being there! Marianne Lund, Oslo, March 2016 Contents 1. Introduction ......................................................................................................................................... 1 1.1 Aim of the study ............................................................................................................................ 1 1.2 Concepts ........................................................................................................................................ 2 2. Background .......................................................................................................................................... 5 2.1 Tobacco policy controversies ........................................................................................................ 5 2.2 Hardening or softening? ................................................................................................................ 6 2.2.1 Hardening conceptualized as increased social disadvantage ................................................ 8 2.2.2 Hardening associated with increasing mental illness among smokers .................................. 9 2.3 The non-smoking hegemony and denormalization of smoking .................................................. 10 3. Theoretical perspectives ................................................................................................................... 13 3.1 The “poor smoker” thesis ............................................................................................................ 13 3.2. Neutralization of risk .................................................................................................................. 14 3.3 Stigma .......................................................................................................................................... 17 3.4 Resistance theory ........................................................................................................................ 18 3.4.1 Psychological reactance ....................................................................................................... 18 3.4.2 Everyday resistance .............................................................................................................. 19 3.4.3 A social resistance framework .............................................................................................. 20 4. Data and methods ............................................................................................................................. 23 4.1 The Norwegian Tobacco Survey .................................................................................................. 23 4.2 Internet-based surveys ................................................................................................................ 24 4.3 Content validity ........................................................................................................................... 26 4.3.1 Social desirability bias in monitoring smoking behaviour .................................................... 27 4.4 Data analysis ................................................................................................................................ 27 4.4.1 Scale variables: Between and within design ........................................................................ 27 4.4.2 Principal component analysis ............................................................................................... 28 4.4.3 Categorical variables: Regression analysis ........................................................................... 29 5. Summary of the research papers ...................................................................................................... 31 6. Discussion .......................................................................................................................................... 33 6.1 Hardcore smokers and the question of resistance ..................................................................... 33 6.2 Denormalization and stigma ....................................................................................................... 35 6.3 Social inequality in smoking behaviour and “the poor smoker” ................................................. 37 6.4 Conclusion ................................................................................................................................... 39 6.5 Directions for future research ..................................................................................................... 40 References ............................................................................................................................................. 41 Appendix Appendix 1: Questions from the Norwegian Tobacco Survey (in Norwegian) Appendix 2: Supplementary table, paper 2 Appendix 3: Questionnaire used in paper 4 (in Norwegian) Summary In Norway, the prevalence of daily smoking has gradually declined from 50% among men and 30% among women in the early 1970s to 13% in both genders in 2015. The rate of occasional smoking has remained stable at approximately 10% in recent decades. Presumably, this decline in the historically prevalent and socially rooted practice of smoking signals the final stage of the tobacco epidemic, which is characterized by an increasing social gradient within the steadily decreasing segment of smokers. Norway was once a pioneer in tobacco control and introduced a comprehensive governmental program to reduce smoking, including a total ban on tobacco advertising starting in the mid-1970s. Since then, most of the policy instruments recommended by the World Health Organization to combat smoking have been implemented. In addition to a robust infrastructure for tobacco control, there has also been a focus on social denormalization strategies to make cigarettes less desirable and less accessible, and the act of smoking less acceptable. However, given the severe harm associated with smoking, the tobacco control community considers the decline in smoking to be too slow. In particular, there has been a concern for a possible asymptotic plateau in smoking rates. Whether smoking rates will tend to flatten in countries that have reached the last phase of the tobacco epidemic has also been an issue for researchers. One approach has been to investigate the number of “hardcore smokers” to test the much-discussed “hardening hypothesis”. Hardcore smokers are inveterate smokers who do not want to or are not able to quit smoking and therefore are considered a difficult segment to reach by traditional tobacco control measures. The hardening hypothesis postulates that the proportion of hardcore smokers will increase as smoking prevalence declines. The overall aim of this thesis is to increase our understanding of those who continue to smoke, as the normative and socio-material climate tends to facilitate non-smoking. I use various survey data sets to address four main topics in this thesis. The first paper investigates the size of the hardcore smoker group and whether the relative size of the group has changed over time in the population of smokers. We concluded that the size of the hardcore group of smokers remains relatively moderate in Norway, and we found little support for the hardening hypothesis. However, this conclusion depends upon
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