Tob Control: first published as 10.1136/tobaccocontrol-2015-052233 on 20 August 2015. Downloaded from Editorials

contact a clinician or quit-line for help Shame-based appeals in a tobacco with quitting smoking. control public health campaign: RISKS OF A SHAME-BASED potential harms and benefits ANTITOBACCO MEDIA APPROACH As with medications, side effects must be considered in terms of likelihood as well Cati G Brown-Johnson, Judith J Prochaska as magnitude. Of concern, in their three- part study Amonini et al did not test for Smoking is the leading preventable cause ethnic minority status and co-occurring increases in experienced shame among of death worldwide, responsible for 1 in mental and physical health disorders.4 viewers. 10 deaths globally (>5 million a year). Capitalisation on shame-based public Prior to dissemination, assessment of Tobacco use adversely impacts not just health campaigns will, in effect, target message impact on shame and stigma smokers, but also those around them these groups. should be examined, particularly among through secondhand smoke exposure. In contrast, the tobacco industry’scam- disadvantaged groups. Broad-based com- Given the significant personal and societal paigns have emphasised themes of freedom, munication interventions will reach those costs of tobacco use, any strategy to affluence and excitement, creating the per- diagnosed with lung cancer and chronic reduce smoking should be considered. ception that smoking is a choice of free obstructive pulmonary disease, who, In this issue, Amonini et al1 report on will.5 In this context, when smokers fail to smoker or not, may internalise the stigma development and evaluation of a shame- quit, they often blame themselves.6 of negative societal impressions. Lung based public health campaign in Perth, cancer stigma is associated with poorer psy- chosocial outcomes14 and morbidity15 Australia. Public health media campaigns SMOKING-RELATED SHAME among smokers and non-smokers equally.16 in Australia, in particular, have raised AND STIGMA As such, shame-based public messages may awareness and instigated behaviour Stigma is a concept derived from classic contribute to stress and increased symptom change via approaches ranging from direct sociology, whereby negative differential ‘ burden. With regard to smokers with and forceful (eg, Belt Up or Suffer the treatment is experienced by groups with ’ 2 mental illness, imagery suggestive of indivi- Pain seatbelt campaign ) to humorous socially ‘discredited’ identities.7 Stigma ‘ ’ duals as lepers or isolates may compound and memorable (eg, Slip! Slop! Slap! for related to smoking is experienced as shame, 3 stereotypes with adverse effects. Explicit skin cancer prevention ). self-judgement and outright discrimination fore-fronting of diversity and gender ana- In developing their tobacco control ad in the form of denial of goods, opportun- et al lyses is a strategy within tobacco control for campaign, Amonini conducted focus ities and services.8 Shame is a central focus protecting such vulnerable groups.17 groups with smokers and interviewed of research on lung cancer stigma (where former smokers, identifying salient themes smokers blame themselves for the disease),9 “ of social isolation (eg, you feel like a and an emergent area of interest with MESSAGE ALTERNATIVES WORTH ‘ ’” leper ). Next, they created and piloted an respect to tobacco use more generally.10 EXPLORING ad prototype in an experimental setting, Research indicates about 40% of In the current study, all messages except http://tobaccocontrol.bmj.com/ which demonstrated believability/relevance smokers and ex-smokers perceive substan- the shame-based ad had previously been fi and perceived ef cacy in stopping smokers tial smoking stigma,11 with a ‘deep divide’ used in public campaigns, and Amonini from smoking. Finally, they created the existing between smokers and non- et al acknowledged a potential novelty shame-based ad, evaluating it in a publicly smokers.12 While a minority of smokers confound effect. Future investigation launched campaign where a majority of report experiencing outright discrimin- should compare multiple novel message fi respondents self-reported in the rst ation (eg, denial of work or housing), themes; worth considering as an alterna- several weeks that they reduced cigarette smokers may withstand many tiny insults tive are shame-free guilt appeals, which consumption (36%), attempted cessation (eg, purposeful coughing in their pres- explicitly do not elicit shame. (16%) or quit (2%). ence, glaring looks from non-smokers).12 Though Amonini et al did not find guilt While suggestive as a promising public Smokers speak of ‘smoking islands’, the to be as effective as shame, shame-free health approach, the potential for harm few remaining areas, largely isolated, guilt messaging has been a powerful on 2 August 2018 by guest. Protected copyright. associated with an emphasis on shame where one can smoke without judg- motivator in other contexts. A recent also bears consideration, particularly ment.13 While cessation is a positive pos- study promoting STD screening found when in relation to a behaviour sustained sible response to smoking stigma, of that shame-free guilt appeals focusing on through addiction and increasingly con- concern is smokers’ reported hiding of behavior (eg, “forgetful behavior”) and centrated among marginalised groups. their use from potential supports, such as the consequence of actions on others (eg, Today, smokers in Australia and other family, friends and healthcare providers.11 to elicit empathy) that identified specific industrialised countries are largely charac- Shame-based antitobacco public health coping strategies outperformed shame terised by lower income and education, campaigns may lead smokers to attempt appeals that focused on intrinsic features cessation in isolation, unassisted. Only of identity (eg, “an irresponsible 3–5% of unaided quit attempts are suc- person”).18 Since Amonini et al did not Department of Medicine, Stanford Prevention Research cessful, and defeated efforts may nega- formally assess the impact of the ads on Center, Stanford University, Stanford, California, USA tively impact smokers by decreasing feelings of shame and guilt, we do not Correspondence to Dr Judith J Prochaska, self-efficacy and increasing stigmatisation know whether the guilt ad utilised was Department of Medicine, Stanford Prevention Research ‘ ’ Center, Stanford University, Medical School Office on relapse. To counteract this potential, shame-free. Future messages assessed for Building, X316, 1265 Welch Road, Stanford, shame-based appeals ought to at elicitation of shame and guilt individually CA 94305-5411, USA; [email protected] minimum include explicit instructions to will be better equipped to help determine

Tob Control September 2015 Vol 24 No 5 419 Tob Control: first published as 10.1136/tobaccocontrol-2015-052233 on 20 August 2015. Downloaded from Editorials the risks and benefits of shame and/or 7 Goffman E. Stigma: notes on the management of guilt messaging. spoiled identity. Englewood Cliffs, NJ: Prentice-Hall Inc., 1963. In exploring novel public health 8 Brown-Johnson CG, Cataldo JK, Orozco N, et al. approaches, studies such as Amonini Validating the Internalized Stigma of Smoking et al’s may move the field forward on the Inventory (ISSI) with a seriously mentally ill To cite Brown-Johnson CG, Prochaska JJ. Tob Control population. UCSF Health Disparities Research path to 100% smoke-free. Consistent with 2015;24:419–420. the Hippocratic oath of ethical practice in Symposium VII. San Francisco, California, USA, 2013. 9 Chapple A, Ziebland S, McPherson A. Stigma, medicine, however, public health efforts shame, and blame experienced by patients with lung above all must do no damage or harm. In cancer: qualitative study. BMJ 2004;328:1470–3. particular, we should consider the effects 10 Brown-Johnson C, Cataldo J, Orozco N, et al. Validity on members of society under-represented ▸ http://dx.doi.org/10.1136/tobaccocontrol-2014- and reliability of the Internalized Stigma of Smoking 051737 Inventory: An exploration of shame, isolation, and in research efforts who are already socially discrimination in smokers with mental health isolated by socioeconomic circumstances Tob Control 2015;24:419–420. diagnoses. Am J Addiction 2015. In press. or association with tobacco-stigmatised doi:10.1136/tobaccocontrol-2015-052233 11 Stuber J, Galea S. Who conceals their smoking status disorders. As tobacco use increasingly from their health care provider? Nicotine Tob Res – becomes denormalized, public health cam- 2009;11:303 7. REFERENCES 12 McCool J, Hoek J, Edwards R, et al. Crossing the paigns must not only attend to positive 1 Amonini C, Pettigrew S, Clayforth C. The potential for smoking divide for young adults: expressions of results, but also guard against harm in vul- shame as a message appeal in anti-smoking television stigma and identity among smokers and nonsmokers. nerable groups. In particular, interven- advertisements. Tob Control 2015;24:436–41. Nicotine Tob Res 2012;15:552–6. tions that risk stigmatizing could backfire 2 World Health Organization, Transport Accident 13 Thompson L, Pearce J, Barnett JR. Moralising Commission of Australia. 40 years of seat-belts— geographies: stigma, smoking islands and by exacerbating health disparities rather Belt up or Suffer the Pain. 2010. http://www.who. responsible subjects. Area 2007;39:508–17. than reducing them. int/violence_injury_prevention/videos/australia_seat_ 14 Brown-Johnson CG, Brodsky JL, Cataldo JK. Lung belts_40_years/en (accessed 10 Nov 2014). cancer stigma, anxiety, depression, and quality of Twitter Follow Cati Brown-Johnson at @catibrown 3 Montague M, Borland R, Sinclair C. Slip! Slop! Slap! life. J Psychosoc Oncol 2014;32:59–73. Funding This work was supported by the National and SunSmart, 1980–2000: skin cancer control and 15 Cataldo JK, Brodsky JL. Lung cancer stigma, anxiety, Institute of Mental Health #R01 MH083684, National 20 years of population-based campaigning. Health depression and symptom severity. Oncology Heart Lung and Blood Institute #HL117736 and #T32 Educ Behav 2001;28:290–305. 2013;85:33–40. HL007034, and the State of California Tobacco-Related 4 Graham H. Smoking, stigma and social class. J Soc 16 Cataldo JK, Jahan TM, Pongquan VL. Lung cancer Disease Research Program #21BT-0018. Policy 2012;41:83–99. stigma, depression, and quality of life among ever and 5 Mejia P, Dorfman L, Cheyne A, et al. The origins of never smokers. Eur J Oncol Nurs 2012;16:264–9. Competing interests JJP has served as an expert personal responsibility rhetoric in news coverage of 17 Amos A, Greaves L, Nichter M, et al. Women and tobacco: witness against the tobacco companies in lawsuits for the tobacco industry. Am J Public Health 2014;104: a call for including gender in tobacco control research, which she has received fees for the work and has 1048–51. policy and practice. Tob Control 2012;21:236–43. provided consultation to Pfizer, which makes 6 Halding A-G, Heggdal K, Wahl A. Experiences of 18 Boudewyns V, Turner MM, Paquin RS. Shame-free medications for quitting smoking. self-blame and stigmatisation for self-infliction guilt appeals: testing the emotional and cognitive Provenance and peer review Commissioned; among individuals living with COPD. Scand J Caring effects of shame and guilt appeals. Psychol Mark internally peer reviewed. Sci 2011;25:100–7. 2013;30:811–25. http://tobaccocontrol.bmj.com/ on 2 August 2018 by guest. Protected copyright.

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