Research paper
Cigarette smoking as a stigma: Evidence from France

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Abstract

Background

There is growing evidence that cigarette smoking has become a stigmatized behaviour, at least in western countries, and there is ongoing debate among experts about whether or not such stigma should be an instrument of anti-tobacco policy.

Methods

We investigated French non-smokers attitudes toward cigarette smokers, using data from a telephone survey carried out in 2010 among a representative random sample of non-smokers aged 15–75 (N = 3091). We carried out a cluster analysis to build contrasted attitudinal profiles and we also computed a score of stigmatization.

Results

We found evidence for the existence of stigma associated with cigarette smoking in France: a majority of French non-smokers would not date a smoker, nor hire one to take care of their children. The cluster analysis identified four contrasting profiles, corresponding to different levels of stigmatization, including one cluster whose respondents demonstrated strong levels of moral condemnation and social rejection of smokers. Older people, those with a lower educational level and those reporting financial difficulties were more prone to stigmatize smokers, while those who reported that somebody smoked in their home were less likely to do so. Those who had never smoked and those who abstained from alcohol were more prone to stigmatize smokers. Obese people were also more likely to do so (in bivariate analysis only).

Conclusion

The process of tobacco stigmatization seems well-advanced in France, despite a cultural context that may be less permeable to this process. Further research is needed as our results raise some questions regarding its efficiency as a policy tool. First, people who are familiar with smokers are less prone to stigmatize them. More generally, simultaneously stigmatizing several categories of people may provide each of these same categories with stereotyped ‘others’ onto whom they can deflect their stigma.

Introduction

Initially coined by Goffman in the 1960s, the concept of ‘stigma’ refers to “an attribute that binds a person to an undesirable stereotype, leading other people to reduce the bearer “from a whole and usual person to a tainted, discounted one” (Goffman, 1963: 11). Goffman distinguished between three types of stigmas: physical handicaps and deformities, blemishes of individual character inferred from deviant behaviours or conditions (e.g. addiction, homosexuality, unemployment), and membership of a particular community (e.g. a racial or religious group). Goffman did not refer to smokers, as smoking was neither a health nor a moral issue in the early 1960s, but today cigarette smoking would correspond to the second type of stigma.

Two main and complementary aspects of stigma are moral condemnation (stigmatized people are usually subject to pejorative labels and negative assessments which emphasize their moral inferiority) and social rejection (‘normal’ people tend to avoid those who are stigmatized). Avoidance of stigmatized people may be driven by either instrumental (when they are perceived as dangerous/contagious) or symbolic motives (willingness to express personal values, to clarify the normative contours of societal boundaries and the consequences of non-conformity). These two motives, which can be referred to as “keeping people away” and “keeping people in” (Phelan, Link, & Dovidio, 2008), are frequently entangled with one another. For example, aversion to contact with a HIV-infected person could be considered as a composite of aversion to strangers, infection, immorality, and misfortune (Rozin, Markwith, & McCauley, 1994). More generally, historians and anthropologists have shown that across time and space people considered guilty of a moral transgression have been frequently perceived as tainted and contagious (Douglas, 1966, Foucault, 1988).

There is little doubt that cigarette smoking has become a deviant and stigmatized behaviour, at least in western countries (Bayer and Stuber, 2006, Goldstein, 1991, Hughes, 2002, Markle and Troyer, 1979, Stuber et al., 2009). For example, in Australia, smokers are routinely depicted in everyday discourse and media representations as malodorous, unattractive, selfish and thoughtless addicts, but also as antisocial polluters and employer liabilities (Chapman & Freeman, 2008). In France, an opinion survey conducted in 1999 suggested that smokers were viewed in a hostile and derogatory way: a majority of the French population view smokers as drug-addicted individuals who should be held responsible for their health problems. They considered that cigarette smoking caused more problems in society than illegal substance use (Beck, Legleye, & Peretti-Watel, 2003).

Prevention campaigns also contribute to compound smokers’ spoiled identities, by portraying them as cigarette slaves, self-indulgent and lacking self-control, and depicting smoking as “a personal vice” and a “sign of weakness” (Lupton, 1995, pp. 128 and 152). Indeed, health has become a sort of ‘super value’, a metaphor for all that is good in life, and personal health is supposed to depend mainly, if not exclusively, on the individual's behaviour: this cultural feature has been labelled ‘healthism’ (Crawford, 1980). Consequently, preserving one's health has become a moral imperative (Lupton, 1995), and unhealthy behaviours tend today to be considered deviant behaviours. ‘Healthism’ could be viewed as an aspect of the contemporary ‘risk culture’ (Giddens, 1991): individuals are exhorted to be continuously aware of risks and opportunities in order to ‘colonize’ their future, and smokers in particular are expected to plan out their long-term health by quitting now. From this viewpoint, people who continue to indulge in unhealthy behaviours such as cigarette smoking show an inability or refusal to secure their future. Accordingly, they break the new behavioural norms promoted by risk culture and ‘healthism’. They deliberately shorten their life expectancy and display their moral inferiority at the same time.

The case of cigarette smoking is also very illustrative of the connection mentioned above, between contagion, immorality and blame. Half a century ago, although still widespread in the population, smoking was already described as a contagious condition:

“Smoking is spread by smokers. Each time a smoker lights up, he proclaims anew his support for the smoking of tobacco (…) Each word of appreciation of smoking also tends to spread the disease. Every smoker is, in fact, actively infectious and makes himself into a gratuitous advertisement for tobacco. (…) Psychological infection of the non-smoker is completed as a rule by the intimate persuasion of a smoker.” (Johnston, 1957: 10–11)

In this quotation, the reference made to contagion was probably at least partly metaphorical. Nevertheless, beyond metaphor, cigarette smoking has been increasingly described as a contagious disease in scientific literature. The World Health Organization promotes the notion of ‘global tobacco pandemic’ with an epidemic diffusion model (WHO, 2003). Furthermore the psychological notion of ‘social contagion’ was applied to cigarette smoking by Glad and Adesso (1976). In addition, in lay people's terms, smoking is a bad example for others, and especially children. Last but not least, smokers are endangering the health of all others around them, due to passive smoking.

As a consequence, there are both symbolic and instrumental motives for physically avoiding smokers, and some empirical studies suggest that non-smokers are, indeed, prone to doing just that. For example, according to Australian studies, advertisements for shared accommodation commonly list non-smoking as an essential attribute in would-be housemates (Chapman, 1992), and people advertising on dating websites overwhelmingly specify that they are looking for non-smokers (Chapman, Wakefield, & Durkin, 2004). Moreover, a survey conducted in New-York found that most smokers anticipate that most non-smokers would be reluctant to date a smoker or to hire her/him to take care of their children (Stuber, Galea, & Link, 2008). In the same study, one current or former smoker out of six also reported an experience of smoking-related discrimination (difficulties in finding a house, a job or a health insurance).

The prevalence of smoking is higher in France than in Anglophone countries (about one third of French adults are current smokers: 30% in 2010, vs 27% in the USA, 21% in the UK, 20% in Canada, and 17% in Australia, see WHO, 2011), despite very similar tobacco control policies, including raising taxes on cigarettes, smoke-free legislation in public spaces, health warnings on tobacco packages and bans on tobacco advertising, promotion and sponsorship. Most of these policies were implemented or strengthened in France during the 2000s, but smokers’ compliance with smoke-free policies was poor, at least at the beginning (Guilbert, Baudier, & Gautier, 2001). Similarly, French tobacconists poorly comply with the law prohibiting tobacco sales to minors, and they also constitute a powerful lobby.

Moreover, cigarettes may have had a culturally valued place in France in ways distinct from their history in Anglophone countries, which is probably why so many of the examples Richard Klein cites in “Cigarettes are Sublime” are from French intelligentsia (we thank an anonymous referee for this remark), including the picture on the book cover (Klein, 1993). Many great figures of contemporary French culture are usually portrayed with a pipe or a cigarette (philosophers like Sartre and Camus, writers like Malraux, singers like Gainsbourg or Bashung), and when the French government first raised the cigarette taxes in 1976, trade unions strongly protested, claiming that cigarettes were an “antidote” to the tensions inherent in workers’ lives (Padioleau, 1977). Cigarettes are still highly valued, at least among the working classes, where there is frequently an intergenerational transmission of smoking (Peretti-Watel, 2012). Thus cigarettes are more likely to be a “cultural artifact” in France than in Anglophone countries (Brennan, 1989). More generally, French people may be less committed to contemporary ‘healthism’, as they are less prone to consider unhealthy behaviours, including fat diet, as an indication of moral or psychological weakness (Stearns, 2002).

The study's aims were threefold: (1) to describe French non-smokers opinions and attitudes toward smokers, and to investigate whether or not indicators of social rejection and moral condemnation combined into meaningful patterns of stigmatization toward smokers; (2) to characterize the socio-demographic profile of non-smokers who are prone to stigmatizing smokers; (3) to provide answers to some questions related to stigmatization motives. First, as people who are committed to ‘healthism’ have symbolic motives to stigmatize smokers, are healthy habits (which may reveal such commitment) positively correlated to the stigmatization of smokers? Conversely, concerning people who are themselves more exposed to health-related stigma: are they less prone to stigmatize smokers? Finally, parents may have an instrumental motive to stigmatize smokers, as they may fear the “psychological infection” of their children. Accordingly, is there a positive correlation between living with children and stigmatizing smokers? These aims were addressed while keeping in mind the specificities of the French context.

Section snippets

Study design and data collection

We used data from ‘Health Barometer 2010’, a telephone survey on health perceptions, knowledge, attitudes and behaviours conducted by the French National Institute for Prevention and Health Education (INPES). It was carried out between October 2009 and July 2010 on a large representative random sample of the general population aged 15–85, living in France and speaking French. This survey was based on a two-stage random sampling design. Residents of collective dwellings, hospitals and

Opinions and attitudes toward smoking and smokers

Non-responses were rare (0–2%, see Fig. 1). Two opinions were endorsed by a majority of non-smokers: higher cigarette taxes are justified (61% of non-smokers agreed or strongly agreed) and smokers set a bad example for young people (60%). About half of respondents stated that they would agree to dating someone who smokes (46% agreed or strongly agreed), and a similar proportion endorsed the following two statements: nowadays, smokers are less accepted by others (48%) and there is a kind of war

Main results

A cluster analysis conducted on a large representative sample of French non-smokers identified four contrasting clusters of opinions and attitudes toward smokers, corresponding to different levels of stigmatization. This included one cluster whose respondents demonstrated strong levels of moral condemnation and social rejection of smokers. Older people, those with a lower educational level and those reporting financial difficulties were more prone to stigmatize smokers than, for example,

Conflict of interest statement

None declared.

Acknowledgements

The French National Institute for Prevention and Health Education (INPES) provided access to the dataset. This research was conducted thanks to a grant from the French Institute for Public Health Research (IRESP).

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