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Keywords:

  • smoking;
  • tobacco use;
  • denormalisation;
  • stigma;
  • tobacco control policy

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. The study
  5. ‘Every space is claimed’: smokers’ views on denormalisation strategies
  6. Smoking as a stigmatised identity
  7. Impacts of denormalisation policies
  8. Conclusion and implications
  9. Acknowledgements
  10. References

Over the past decade, the strategy of ‘denormalising’ tobacco use has become one of the cornerstones of the global tobacco control movement. Although tobacco denormalisation policies primarily affect people on the lowest rungs of the social ladder, few qualitative studies have explicitly set out to explore how smokers have experienced and responded to these legislative and social changes in attitudes towards tobacco use. Drawing on a qualitative study of interviews with 25 current and ex-smokers living in Vancouver, Canada, this paper examines the ways they interpret and respond to the new socio-political environment in which they must manage the increasingly problematised practice of tobacco smoking. Overall, while not opposed to smoking restrictions per se, study participants felt that recent legislation, particularly efforts to prohibit smoking in a variety of outdoor settings, was overly restrictive and that all public space had increasingly been ‘claimed’ by non-smokers. Also apparent from participants’ accounts was the high degree of stigma attached to smoking. However, although the ‘denormalisation’ environment had encouraged several participants to quit smoking, the majority continued to smoke, raising ethical and practical questions about the value of denormalisation strategies as a way of reducing smoking-related mortality and morbidity.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. The study
  5. ‘Every space is claimed’: smokers’ views on denormalisation strategies
  6. Smoking as a stigmatised identity
  7. Impacts of denormalisation policies
  8. Conclusion and implications
  9. Acknowledgements
  10. References

Over the past decade, the strategy of ‘denormalising’ tobacco use has become one of the cornerstones of the global tobacco control movement (see WHO 2008). First pioneered in the state of California (CDHS 1998), tobacco denormalisation ‘can be described as all the programs and actions undertaken to reinforce the fact that tobacco use is not a mainstream or normal activity in our society’ (Lavack 1999: 82). Although a distinction is increasingly being made between ‘social’ and ‘tobacco industry’ denormalisation strategies (Hammond et al. 2006), broadly speaking, the concept has been used to capture a variety of policies and interventions that aim to influence social norms related to tobacco use, targeting smoking behaviour, tobacco products and the tobacco industry (Thrasher 2006). Specific policies and interventions include: limiting where smoking may take place, how tobacco products may be sold and advertised, informing the public about the dangers of secondhand smoke through media campaigns (Lavack 1999), and raising people’s awareness of the tobacco industry’s culpability for tobacco-related disease (Hammond et al. 2006).

Denormalisation activities ultimately aim to utilise the power of social pressure to make smoking ‘less desirable, less acceptable and less accessible’ (CDHS 1998: 3). Arguably, the most successful of these strategies in ‘denormalising’ tobacco use has been location restrictions on smoking, which have been enacted with increasing frequency over the past 15 years. While such location restrictions have historically taken the form of smoking bans in enclosed public spaces, tobacco control advocates are also pushing for smoking bans in outdoor spaces such as hospital grounds and recreational areas.

While such moves have generally been justified in terms of protecting non-smokers from the harmful effects of secondhand smoke, it is important to note that the harms of cigarette smoke in outdoor settings are not comparable to those experienced in enclosed settings and are supported by ‘flimsy’ evidence (Chapman 2000, 2008). Such developments demonstrate the ways in which arguments regarding the effects of tobacco smoke on bystanders have been used as a kind of ‘backdoor’ attempt to indirectly affect smokers’ access to and use of tobacco. Indeed, a reduction in overall smoking prevalence is often seen to be an explicit benefit of such legislation1 (e.g. Department of Health 2006). Thus, location restrictions epitomise the central logic of denormalisation strategies, where ‘cessation is the outcome rather than the intervention’ (CDHS 1998: 9).

Tobacco control in British Columbia

The Canadian province of British Columbia (BC) has long been seen as a global leader in tobacco control and was an early adopter of denormalisation policies – which form the fourth pillar of the provincial strategy2 (BC Ministry of Health Services 2004). Indoor smoking bans have been in place in Vancouver since 1996 and bars and nightclubs have been subject to the ban since 2000; recent municipal legislation is also beginning to restrict smoking in outdoor settings. For example, in 2008 the city of Vancouver prohibited smoking within six metres of the entrances and exits of buildings (City of Vancouver 2008).

Outdoor smoking bans have also been proposed on patios, beaches and other outdoor spaces, and Vancouver looks set to follow the lead of the neighbouring city of White Rock, which in 2008 implemented a smoking ban at parks, recreational areas, the beach and other public outdoor spaces (City of White Rock 2008). Several health authorities in the province have also enacted grounds bans on smoking and organisations such as the Clean Air Coalition of BC are also lobbying strata councils to enact smoke-free apartment bylaws (CACBC 2008). Clearly, in many respects, Vancouver represents the ‘wave of the future’ as policies enacted at the local level get taken up both nationally and internationally.

While such policies are generally deemed responsible for the low smoking prevalence in BC, which at 14 per cent is the lowest in the country (Health Canada 2007), tobacco use is substantially higher amongst marginalised groups in the province. For example, the 59 per cent smoking prevalence in some First Nations communities (First Nations Centre 2005) reflects the growing concentration of smoking amongst the poor and disenfranchised, both in Canada and in industrialised countries more broadly (Jarvis et al. 2003, Bayer and Stuber 2006). Indeed, tobacco control policies are at least partially responsible for the present socioeconomic discrepancies in smoking prevalence, because such policies have historically had a greater impact on the better off (Killoran et al. 2006, Barnett et al. 2004).

Despite these fundamental changes that have occurred over the past decade in smokers’ abilities to access and use tobacco in public spaces, and the fact that such policies primarily affect people on the lowest rungs of the social ladder, few qualitative studies have explicitly set out to explore how smokers have experienced and responded to these changes in tobacco control policy. However, several relevant notable exceptions exist, including Poland’s (2000) exploration of the interpersonal management of smoking in public places in Ontario, Canada, Thompson and colleagues’ (2007) study of disadvantaged smokers’ experiences of smoking-related stigma in New Zealand and Kelly’s (2009) recent ethnographic research on club-going young adults’ experiences of smoke-free legislation in New York nightclubs.

Tellingly, most of the research that has been conducted takes the form of cross sectional surveys or longitudinal studies (see Bell et al. 2009) that aim to evaluate the acceptability of such policies with the larger goal of marshalling evidence to support their expanded implementation. The profusion of such studies and attendant lack of qualitative research into smokers’ experiences (both positive and negative) of these policies speaks to the ways in which tobacco research is increasingly expected to further the goals of tobacco control (Mair and Kierans 2007).

This paper addresses this oversight by exploring smokers’ experiences of tobacco denormalisation policies in Vancouver, Canada. Rather than adopting any normative stance towards tobacco as intrinsically ‘bad’, our goal is to examine the impact of such policies on the lives of participants and the ways they interpret and respond to the new socio-political environment in which they must manage the increasingly problematised practice of tobacco smoking.

The study

  1. Top of page
  2. Abstract
  3. Introduction
  4. The study
  5. ‘Every space is claimed’: smokers’ views on denormalisation strategies
  6. Smoking as a stigmatised identity
  7. Impacts of denormalisation policies
  8. Conclusion and implications
  9. Acknowledgements
  10. References

The findings presented here are based on data collected as part of a pilot study that explored smokers’ interactions with general practitioners (GPs) around smoking and the ways in which the broader socio-political environment affects these interactions. Although the study included interviews with both smokers and GPs, this paper focuses specifically on key findings from the interviews with smokers and ex-smokers about the impacts of tobacco control policies on their daily lives.

The interviews were conducted over a seven-month period between September 2008 and March 2009. The majority of participants were recruited through advertisements in local newspapers. In order to be included in this study, participants had to be current smokers or recent ex-smokers (i.e. quit within the past two years). There were 25 participants in total: 21 smokers and four ex-smokers. In total, 13 men and 12 women were interviewed. The age of participants ranged from 21 to 75, and 21 were white; the remaining participants included South Asian, Persian, Turkish and Chilean immigrants. Eight participants smoked a pack or more a day, 11 smoked more than a pack per week but less than a pack per day, and two were lighter smokers, smoking under a pack per week.

There was a considerable range in social class among the participants, as indicated by education level and occupation. The education level among the participants varied from grade eight to postgraduate degrees: the majority of participants had completed some college-level education or higher, while eight had completed high school or less. Eight participants were unemployed at the time of the interview: three were retired, three were on sick or disability leave, and two were otherwise not working. The majority of interviewees worked in blue-collar and semi-skilled white-collar positions (e.g. secretarial, lower-level sales), with a further two professionals (e.g. lawyer) and two undergraduate university students included in the study.

Interviews were conducted by two members of the research team (McCullough and Bell) in locations convenient for participants (e.g. our offices, participants’ homes, coffee shops). With the consent of the participants, all the interviews were recorded (bar one, at the request of the interviewee) and transcribed verbatim. Participants received a $25 honorarium for participating in the study. Interviews lasted about one hour and open-ended interview questions were based on a semi-structured interview protocol covering a range of topics including: smoking history and habits, the public’s attitude towards smoking, their interactions with their doctor around smoking, and the role they saw doctors playing in smoking cessation.

A description of key themes and findings emerged after numerous reviews of the interview transcripts. For the initial analysis, two team members independently read the interview transcripts in full and noted meaningful segments about personal opinions and experiences of smoking-related issues. This process was repeated for each interview to extrapolate the most reliable themes and sub-themes. An initial coding framework was then sketched out, with differences of opinion resolved through discussion. The remaining members of the research team independently read a subset of four interview transcripts to determine key themes and the final coding framework was developed at a full team meeting based on input from all the team. Qualitative data analysis software was used to facilitate coding and management of the data based on the established coding framework.

The material presented in this paper relates specifically to the study participants’ attitudes towards recent changes in tobacco control policies, the ways such policies have impacted on their daily lives and the ways they have responded to these shifts.

‘Every space is claimed’: smokers’ views on denormalisation strategies

  1. Top of page
  2. Abstract
  3. Introduction
  4. The study
  5. ‘Every space is claimed’: smokers’ views on denormalisation strategies
  6. Smoking as a stigmatised identity
  7. Impacts of denormalisation policies
  8. Conclusion and implications
  9. Acknowledgements
  10. References

There was a substantial degree of consistency in participants’ views on tobacco control policies in British Columbia. A common observation was that although restrictions on smoking were not intrinsically problematic, such restrictions had gone too far in recent years. The following exchange occurred with Bill, a man in his late fifties:

LM: What do you think about some of the policy changes and how—?

Bill: I’m all for it, I’m all for it… To the extent where, okay, the message is out, enough is enough. You know, like, if I’m walking down the street and having a cigarette and somebody comes up to me and goes ‘Oh, that’s a filthy habit’, I don’t like that.… Yeah, I mean, you know, okay it’s a health issue but don’t take everybody’s rights away.

A woman in her mid-twenties, Aisha, also emphasised the need for smoking restrictions, but similarly expressed the view that they had reached the point of ignoring smokers’ rights:

I think, I mean I don’t doubt for a minute that it’s [secondhand smoke] a health risk. So anybody that smokes, for sure I have no problem with the limits up until I would say like the mid-nineties, yes. Like, up to the point of banning from any indoor spaces, that’s fine, because they’re infringing on other people’s rights to breathe smoke-free air. But I think probably in the last 10 years people have gone way too far and they have a completely hypocritical approach.

Alex, a woman in her late fifties, also highlighted the erosion of smokers’ rights the present socio-political environment had engendered:

LM: How do you think the general public views smoking? I remember you said before, you think there are some groups that are really—

Alex: Oh yeah, like the Nazis, the smoking Nazis.

LM: Yeah.

Alex: Oh, they’re horrible.

LM: Do you feel that’s—?

Alex: I feel they’re trying to take our rights away from us… Like, I have rights, too. I try not to smoke around bus stops or, you know, places where old people or children are. But damn it, I have the right to have a cigarette.

Similarly, smokers in Thompson et al.’s (2007) study also tended to frame their smoking in terms of ‘rights’ discourses, whilst simultaneously noting the ways that non-smokers’ rights appeared to become paramount to the point of ‘pushing out’ smokers.

Brandt (1998: 175) has pointed out that the debate about smoking has increasingly been framed in North America as a conflict in rights: non-smokers have insisted on the ‘right’ to a smoke-free environment and smokers have accused non-smokers of ‘health fascism’ and have simultaneously invoked their own right to smoke. The resulting impasse demonstrates the limitations of human rights discourses in the context of drug use. As Keane (2003: 227-228) notes, rights often come in contradictory pairs. Thus, the ‘rights’ of drug users invariably become pitted against the ‘rights’ of other groups, such as the rights of children to drug-free parents and the rights of non-drug users to be protected from drug use. When framed in these terms, the ‘rights’ of the ‘innocent victims’ of tobacco smoke are invariably seen to trump the ‘rights’ of smokers to smoke (Kagan and Vogel 1993, Brandt 1998, Berridge 1999, Bayer and Colgrove 2002).

Yet, it is important to note that without exception, study participants acknowledged that they did not have the ‘right’ to smoke indiscriminately, oblivious to their surroundings, and emphasised that smoking should be regulated to some degree. Indeed, as has been previously observed (Poland 2000, Coxhead and Rhodes 2006, Thompson et al. 2009), the study participants frequently invoked discourses of consideration and responsibility as a central organising logic in accounts of their smoking. These included practices such as asking permission to smoke, smoking away from non-smokers in public places, and not smoking around children.

Rachel, a woman in her early fifties, provided a fairly typical account of the ways in which smoking restrictions undermined her efforts to ‘do the right thing’:

I’ve been in transit through airports and gone outside and I’m conscientious, right, I don’t—if somebody says ‘Hey that’s bothering me!’ I’m out of there or put it out or something, you know?... But I think it’s getting a little bit too—we’re getting put on too short of a leash in some respects. I can’t remember which airport it was, but I went outside, I looked around, didn’t see any of the obvious ‘No Smoking’ [signs]. I was away from the door, lit up and a security guard came over and he said, ‘You’re in a no smoking area’…‘The smoking area is downstairs’. ‘Okay’. So even though I’m outside and I’m away, you know, I get—every space is claimed.

Rachel demonstrated acute concern with the effects of her smoking on others and actively took steps to minimise their exposure. However, her account demonstrates the ways in which denormalisation has made it increasingly difficult for smokers to smoke at all in public, thereby suggesting that they have lost both epistemic and material claims to all public space – indoors or outdoors.

A number of participants appeared intuitively to grasp that in relation to such policy changes, far more was at stake than the public’s exposure to secondhand smoke. In several interviews, participants expressed the view that recent smoke-free legislation constituted an implicit attempt to create de facto ‘prohibition’– a term several study participants used to describe recent developments. For example, the following exchange occurred with Alex, a woman in her late fifties:

LM: The next question is, have attitudes changed since you first started smoking?

Alex: Definitely. Big time… It’s almost intimidating, you’re almost intimidating people that they can’t have a cigarette.

LM: Hmm.

Alex: And you know what? Prohibition didn’t work for alcohol, it’s not going to work for tobacco.

Cameron, a man in his late fifties, also characterised recent legislation as a form of prohibition:

And I do think that it’s [smoke-free legislation] a way that government does intrude into your personal life. I think it is a way of controlling morality, which I think government maybe should not be involved in, though at the same time I really believe that non-smokers have their rights as well… But this blanket kind of prohibition I think is verging on fascist behaviour… And I think it’s about, you know, again, non-smokers have rights, but I think there can be fanaticism, like overreaction.

Cameron, like Alex, Aisha and Bill, used the lexicon of ‘rights’ to discuss his views on smoking; he was, however, more explicit than other participants in connecting these legislative changes with attempts to control individual morality and government intrusions in the private lives of its citizens.

Smoking as a stigmatised identity

  1. Top of page
  2. Abstract
  3. Introduction
  4. The study
  5. ‘Every space is claimed’: smokers’ views on denormalisation strategies
  6. Smoking as a stigmatised identity
  7. Impacts of denormalisation policies
  8. Conclusion and implications
  9. Acknowledgements
  10. References

In the context of relaying changes in the broader policy environment, many study participants described smoking as a highly marginalised and deviant behaviour. According to Bob, a man in his late fifties:

My personal opinion is that the social climate is, I mean, I can’t tell you how many times you’d be off having a cigarette in the designated smoking area 19 yards away from where you’re supposed to be, and someone will look at you and while they’re standing there they go ‘Yeah, welcome to crack corner’ (laughs).

A number of interviewees made comparisons between tobacco and illicit drugs, particularly crack cocaine, expressing the view that in Vancouver tobacco use was seen to be on a par with smoking crack. For example, the following exchange occurred with Mark, a man in his mid-forties:

Mark: I would never go to somebody’s house and ask them if I could smoke, put it that way. I wouldn’t even put them in the position.

LM: It’s so automatic, and if you ask that they would go—.

Mark: ‘Can I go in your bathroom and smoke crack?’

LM: Wow, it’s up there, hey?

Mark: It seems like that to some people, oh yeah, yeah, I think so, yeah, I think so.

In light of these assessments regarding the relative social acceptability of tobacco use, many participants highlighted a sense of discomfort in smoking in public – even in places where they were theoretically ‘allowed’ to smoke. This sense of felt stigma was often accompanied by descriptions of enacted stigma (Scambler and Hopkins 1986), where smokers were subject to negative comments as well as nonverbal actions that implied criticism and judgement of their smoking (e.g. fake coughing, nose holding, frantic hand waving, etc). Indeed, the majority of smokers we interviewed told stories along these lines in response to general prompts about how the public viewed smoking. For example, the following exchange occurred with Pete, a smoker in his mid-twenties:

LM: So do you want to talk anything more about that, like how you think the public view it or the differences between—[smokers and non-smokers]?

Pete: Um—yeah, it’s definitely a negative connotation now, like you’re weak willed or whatever because you’re not quitting… Oh yeah, like, you know, like, if I go outside the [university] library and I have a smoke, people are kind of looking at me ‘Look at this guy!’ you know, like—

LM: Oh really?

Pete: Yeah, and I’d be all self conscious, yeah.

A woman in her fifties, Mary, also expressed similar views. Although Mary asked not to have her interview recorded, interview notes provide an indication of the content of her interview:

We then discuss the public’s views on smoking and Mary notes, ‘Smoking is really frowned on’. During the weekends she is out more in public and someone will make a comment – this has really increased in the last year [since the smoking bylaws were brought in]. Mary indicates that ‘People look at you and comment’. You’ll hear someone say, ‘they’re still smoking here’. People say this even if she is ‘15 feet from the door’. She then notes that people in Vancouver in general seem to have a lack of ‘manners’. She clarifies: ‘I don’t want to say they’re unfriendly but people are not courteous’. Unhappy with this characterisation she then says, ‘If someone doesn’t like smoking then they say it. They’re very direct’.

Eve, a woman in her early thirties, made similar observations about the non-verbal reactions she received from people when she smoked in outdoor spaces in public.

Eve: So I mean, everybody looks at me funny, people walk by they clear their noses, they cover their faces while I’m smoking.

LM: Really?

Eve: Oh yeah!

LM: Wow.

Eve: If I light a cigarette, even off the side of the bus stop, whoever’s at the bench will get up and move the other way. I’ve had people do that. They’ll get up and move and give me the worst look in the world because I’m a smoker.

These accounts demonstrate the ways in which smoking in public, by definition, has come to be regarded as discourteous. Thus, responses to smokers that would otherwise be perceived as rude or intrusive are made permissible by the denormalisation environment.

Aside from the censure many participants described receiving in response to their smoking, some voiced a sense of active discrimination from non-smokers. For example, Bob, a man in his late fifties, noted:

…Even if you can’t articulate it you probably intuitively feel it in the same way that if you’re black or a woman and you’re being discriminated against, like even if you can’t articulate it or you certainly can’t prove it or you’d be at the Human Rights Commission, but you kind of know it’s happening.

In this vein, Aisha described her reaction to being refused entry on a bus because she had been smoking at the bus stop:

Aisha: Like, I have had bus drivers not let me on the bus.

LM: Why?

Aisha: Because I was smoking at a bus stop. Open, not even covered, like.

LM: Wow.

Aisha: Open, nobody around me. There isn’t like a three-year-old child next to me, and I’m not breathing smoke in their face or anything, and by myself smoking and they like won’t let me on. They haven’t let me on the bus.

LM: What do they say? What could their rationale be?

Aisha: That you’re not allowed to smoke at a bus stop. And I say ‘Fuck, I’m not’. That’s not true at all… [R]ight now you’re not allowed to smoke at a bus stop that’s covered, under the cover, the rationale being that other people want to huddle under the cover, especially when it’s raining and that’s the way it’s supposed to be, and that’s fine. But a bus stop that’s literally like a post in the street – fuck you! I can smoke here all I want!

Aisha’s experiences speak to the ways in which denormalisation strategies have ‘deputised’ non-smokers as agents of the state3 (Brandt 1998: 174). They also speak to the growing intolerance such strategies have instilled regarding any exposure to secondhand smoke.

Importantly, some study participants emphasised that it was not merely their behaviour that was judged; they also talked of being labelled as a ‘smoker’, implying that the act of smoking created an undesirable social identity. As Bill noted, ‘sometimes, you know, you really are labelled as a bad person if you smoke’. Thus, Josh, a man in his thirties, noted the surprise people expressed when they found out he smoked and the difficulty they had reconciling this with their prior image of him:

Josh: They [non-smokers] tell you: ‘what are you doing to yourself, you’re such a nice boy, why do you have to smoke?’, you know? But I even, like, somebody will come up to me all the time and say that ‘Oh, why do you smoke?’, you know. Like, I don’t know why, I wish I didn’t smoke, but I do…

LM: What kind of reactions have you gotten?

Josh: Um, I’ve gotten ‘Oh, you don’t look like a smoker’. I’ve gotten that one a lot… Like, even other people I meet, like, nice, like, just random strangers are like, ‘You shouldn’t smoke!’ Like, I get that once in a while, girls come up to me and say, ‘You shouldn’t smoke. You look nice, why do you gotta smoke for?’ I’ve had that one a couple days ago.

Evident here is the way in which smoking is juxtaposed to a ‘nice’ and ‘considerate’ social identity.

Although tobacco control advocates stress the need to be ‘antismoking’ not ‘antismoker’, current attitudes towards smoking in Vancouver appear to fit Erving Goffman’s (1968) definition of stigma as an attribute that attaches not only to individual behaviour but social identity itself. However, as Burris (2008) asks, exactly how discrediting is smoking? He points out that public health efforts to marginalise unhealthy behaviours should not automatically be seen as ‘stigma’ and advocates against an ‘effete sensitivity in which even the least whiff of social disapproval of a behaviour is seen as coercive or stigmatising’ (2008: 475). This is an important question, especially in light of recent sociological criticisms that stigma has been too vaguely and broadly defined and is therefore in danger of losing its utility as a concept (see Link and Phelan 2002 for a discussion).

One highly regarded definition has been proposed by Link and Phelan (2002), who suggest that stigma, properly defined, entails five key attributes: (1) distinguishing and labelling differences; (2) associating differences with negative attributes; (3) separating ‘us’ from ‘them’; (4) status loss and discrimination; and (5) the dependence of stigma on power. In our view, the sorts of experiences reported by smokers in our study do fit this more restricted definition of stigma. Participants’ descriptions indicate that smokers in Vancouver are indeed labelled, stereotyped and suffer from status loss in ways that suggest a form of spoiled identity that is more constantly than occasionally precarious (to paraphrase Goffman). Moreover, such labels and stereotypes are connected with moves to discriminate against smokers in the context of employment and insurance (Stuber et al. 2008), and, as we have argued elsewhere, healthcare (Bell et al. 2010). It is also important to acknowledge the radical degree to which public space (outdoors as well as indoors in Vancouver) has been divided in order to segregate smokers from non-smokers.

Given the class composition of smoking and the growing concentration of smoking amongst the poor and disenfranchised, stigma is clearly dependent upon social, cultural, economic and political power differences between smokers and non-smokers. Indeed, several scholars (e.g. Berridge 1999, Poland 2000, Bayer and Colgrove 2002) have pointed out the connection between the decline in smoking amongst the dominant classes and its discursive reconstitution as an undesirable and unhealthy behaviour. Smokers are therefore subject to dual stigmatisation, as the stigma connected with smoking becomes connected with and compounds the stigma connected with socio-economic deprivation (Thompson et al. 2007).

Impacts of denormalisation policies

  1. Top of page
  2. Abstract
  3. Introduction
  4. The study
  5. ‘Every space is claimed’: smokers’ views on denormalisation strategies
  6. Smoking as a stigmatised identity
  7. Impacts of denormalisation policies
  8. Conclusion and implications
  9. Acknowledgements
  10. References

Although responses to this new socio-political environment varied, several types of reactions were notable in participants’ descriptions of their experiences of negotiating the impacts of increasingly restrictive smoking restrictions and the negative responses they received when they smoked in public.

Quitting smoking

Three of the people interviewed – all female recent ex-smokers – voiced unqualified support for recent tobacco control polices in Vancouver and felt that these policies had been helpful in quitting smoking. For example, the following exchange occurred with Louise, a woman in her late forties:

Louise: I think lately it’s [smoking] not acceptable, like, even more and more becoming unacceptable. And also the new laws, you know, going in like in your public areas and that, and also not, like a pub, outside pub areas. It’s not acceptable any more, and it’s becoming more and more unacceptable.

KB: Right. And what do you think of it, how do you feel?

Louise: I agree, yeah, 100 per cent I agree.

KB: Right. Okay.

Louise: I probably would never have agreed, and might have taken a totally different stance when I was smoking but now I 100 per cent agree.

Jackie, a recent ex-smoker in her twenties, had similar views. Jackie had been a smoker when she moved to British Columbia and recalled being surprised and offended by the fervent anti-smoking culture, although she fully endorsed it as an ex-smoker:

Jackie: I had this woman go like (this), waving her arm around at me one time, and I—was just like ‘Whoa lady, you know I have the right to smoke!’ But you can’t smoke, they passed a law of like you can’t be like near doors or windows or bus stops when you have a cigarette, like soon after I moved there. And it was just like after the lady did (this) to me, and I’m looking at my pack and everyone looked so—

LM: Wow.

Jackie: I think I’m thankful for that lady because after I quit I was doing that to other people (laughs). I was just like ‘you stink’, you know, especially after you quit it smells disgusting.

Gabriela, too, endorsed the new socio-political changes in attitudes towards smoking whilst simultaneously noting how difficult negative public responses had been to deal with when she was still smoking:

Gabriela: The most laws they are going to put to avoid people smoking, is the better… When I am with the smoking and trying to quit the last time, I was with my cigarette and everyone was watching me like I had like a marijuana cigarette or something! Everybody was ‘ohh!’

LM: Oh really? Oh, so you got a sense from people.

Gabriela: So I feel—yeah, I feel like before don’t like other people smoking in the street especially. So yeah, and I’m use, oh my God, I shouldn’t be smoking, so these people, they don’t look at me like that in that way. But yeah, that was my feeling… And I feel like everybody was looking at me. I said ‘Oh my God, I should quit, I shall quit.’

Overall, Louise, Jackie and Gabriela all felt that recent changes in tobacco control policy supported (and encouraged) their decision to quit. In many respects, these women can be seen as denormalisation ‘successes’– smokers induced to quit because of the stigma attached to smoking and the inconvenience caused by restrictions on their ability to smoke. However, as Burris (2008: 475) asks: even if effective, how ethical is it for the state to implement the ‘decentralised and visceral mode of social control’ that characterises stigma? He concludes that it is necessary to watch for signs that smokers are becoming social pariahs, are being stereotyped or suffering status loss or are beginning to internalise negative social attitudes and punish themselves.

Judging selves and taking up stereotypes

A far more common response to tobacco denormalisation amongst participants in the study was to internalise a sense of ‘outsiderness’ (Thompson et al. 2007) and spoiled identity. Similar to Thompson and colleagues’ findings, rarely did participants speak about their smoking in positive terms and many interviewees readily voiced popular stereotypes about themselves as ‘weak-willed’, ‘stupid’, ‘gross’ or ‘dirty’. Josh noted, ‘I feel like such a slob, smoking all the time’ and emphasised the guilt he felt about smoking. Some participants used particularly strong language to describe their smoking. For example, the following exchange occurred with Mark:

LM: Well, how do you feel about your smoking?

Mark: I don’t like it.

LM: No?

Mark: No… I think people lie if they say they enjoy it.

LM: Oh, really?

Mark: Yeah, I do… Yeah, I mean that’s like a heavily overweight person is so comfortable with their weight. I don’t believe it, you know, deep down… It’s [smoking] just a dirty little thing.

Pierre, a man in his early thirties, described his smoking as follows:

LM: And how do you feel about your smoking?

Pierre: Stupid.

LM: You just feel like ‘why am I doing this?’ kind of thing? ‘This is stupid, I know this isn’t good’? What do you mean? What do you mean it’s stupid?

Pierre: Well, when I’m like, not doing sport but I’m maybe running, or shortness of breath. The morning, the morning cough, like before I had put the tar, so to see the thing… It stinks and [it] didn’t make me impotent yet, but—

Many of these participants, however, also expressed a sense of helplessness in quitting. According to Eve, ‘It’s not a very nice habit, it’s not. And you know, I just, I wish I could quit, I’m just having a hard time, because everybody else around me smokes’. As Josh said, ‘I wish I didn’t smoke, but I do’. Similarly, Mary in her interview noted, ‘I don’t want to be a smoker any more’– although she also indicated that she was not ready or able to quit smoking ‘yet’.

Thompson and colleagues (2007) describe the ways in which stigma can produce a type of despairing logic whereby people feel that giving up smoking is too difficult, and conclude that the increased stigmatisation of those who continue to smoke may therefore reinforce continued smoking. These findings combined with our own raise questions about the assumption that denormalisation policies will inevitably lead people to quit smoking (see Bayer 2008). As Burris (2008: 475) asks: ‘where is there good evidence that inculcating a sense of spoiled identity is a good way to get people to adopt healthier behaviours?’

Changes in smoking behaviours

Although some participants in the study indicated that their smoking patterns had changed relatively little since the introduction of tobacco denormalisation policies, many demonstrated an awareness of the impact of stigma on smoking behaviours and the potential it created for ‘closet’ smoking. Thus, Alex joked at one point in her interview: ‘It used to be, people would huddle in their house and have a joint, right? Now it’s people huddling in their house and having a cigarette! You just don’t want to deal with the public’. Others spoke of the ways that the experience of stigma had caused them to confine their smoking to particular settings such as their home or other limited environments where they knew it would be accepted – such as in the company of smoking friends.

In the following exchange Mark highlighted the ways his behaviours had changed as a result of social transformations in attitudes towards smoking in Vancouver:

LM: What do you think has been some of the reasons for some of those changes in attitude in the general public?

Mark: A lot of smoking bans, more people speaking up and saying that they don’t like it, don’t want to be around it. I think people are more verbal about it right now… And it works. I don’t smoke walking down the street—I feel like I’m offending somebody.

LM: Really?

Mark: Uh huh.… Yeah. It’s always an embarrassment, yeah.

LM: Do you have cigarettes with your friends?

Mark: Yes, yes I do. Yeah, so I know who they are and I can, you know what I mean? It’s just socially unacceptable, I find, you know.

Other interviewees were more explicit about the ways they now limited their smoking to particular ‘safe’ contexts. For example, in her interview Mary noted that she increasingly confined smoking to her ‘own backyard’. Interview notes provide further context for these comments:

In response to questioning about the contexts in which she smokes Mary notes that it is mainly when she is watching TV or on the phone… Socially she smokes ‘less and less’ and now tends to smoke ‘by myself’ as these days … She continues that ‘I am really uncomfortable smoking anywhere other than my backyard’. I inquire whether she means this literally – that she literally only smokes in her backyard and she indicates that she is talking figuratively – that she only smokes at home or the ‘backyards’ of friends who are comfortable with it.

Cameron also drew very explicit links between the denormalisation environment in Vancouver and his smoking behaviours:

Cameron: There was an example recently and she [a woman] was smoking in her apartment and the apartment next door was complaining. Now I think that’s carrying it a bit far, and that’s the kind of attitude that I’ve seen from friends, from relatives, from acquaintances and just people on the street.

KB: Right. So does that affect how and where and when you smoke?

Cameron: Oh, absolutely!

KB: So can you tell me a bit about that, I mean, in terms of where you mostly smoke now?

Cameron: I mostly smoke at home.

A similar exchange occurred with Michelle, a woman in her late fifties:

Michelle: Nowadays, you know, you have to pick your spots, too… I don’t smoke out in public. As I say, I have my moments of cigarette smoking, and I anticipate and I look for it, do you know what I mean?

LM: Yeah.

Michelle: So at the end of the day I would have a cigarette and a drink. Do you see what I’m saying?... And so if I was in a social situation where we were going out for dinner, I would not smoke either in or outside—I just don’t do it. So I haven’t come up against the sitting in the bus stop being yelled at by someone, because I don’t smoke in those situations. See what I mean?

These responses echo participants in Poland’s (2000) study, several of whom revealed that they no longer felt comfortable smoking in public and had confined their smoking to private settings or those where tacit approval could be assured. As Poland concludes, ‘One of the effects this may have is increasingly to exclude these people from the public realm, pushing them into the private spaces of the home (where available) or other moments of guaranteed solitude (away from non-smokers), or (conversely) kinship with other smokers’ (2000: 11).

The possibility that wholesale indoor and outdoor smoking bans in public places may serve to push smoking into the home (thereby increasing exposure in those settings) is not so far fetched. Indeed, there is some research to suggest that wholesale smoking bans in public places do increase the exposure of non-smokers in the home. Based on a secondary analysis of data from a series of National Health and Nutrition Examination Surveys, Adda and Cornaglia (2006) argue that smoking bans in bars, restaurants and recreational facilities appear to increase the exposure of non-smokers, particularly young children from lower socio-economic backgrounds. They interpret this as the ‘substitution effect’ between leisure activities in public places where regulation can be enforced and in private spaces where it cannot.

Conclusion and implications

  1. Top of page
  2. Abstract
  3. Introduction
  4. The study
  5. ‘Every space is claimed’: smokers’ views on denormalisation strategies
  6. Smoking as a stigmatised identity
  7. Impacts of denormalisation policies
  8. Conclusion and implications
  9. Acknowledgements
  10. References

Clearly, smokers in Vancouver have witnessed radical changes in attitudes towards smoking over the last decade as tobacco use has become increasingly ‘denormalised’. While the legislative environment in Vancouver and British Columbia is more restrictive than in other regions, it represents a direction that many states are increasingly moving towards, in an effort to reduce the social and economic costs of smoking-related morbidity and mortality.

Participants in our study highlighted the growing restrictions on their ability to smoke and several explicitly recognised that legislative measures went well beyond the goal of protecting non-smokers from exposure to the effects of secondhand smoke and that the right to smoke altogether was being steadily eroded. Thus, while many participants expressed the view that smoking restrictions themselves were not intrinsically problematic, they emphasised that tobacco denormalisation had created an environment in which every public space was ‘claimed’ by non-smokers, making it impossible to smoke in public at all without receiving judgement. Importantly, while study participants expressed considerable felt stigma in relation to their smoking, they also recounted numerous instances of overt censure and discrimination.

Smokers’ experiences in Vancouver raise important questions about the value and ethics of denormalisation strategies. Should a liberal state ever be complicit in shaming its citizens (Nussbaum 2004: 232)? Will humiliating and stigmatising smokers even work and if so, under what conditions, and with what consequences? Our research suggests that while denormalisation strategies may promote cessation for a certain segment of the population, their iatrogenic consequences (Castel 1991) need to be further studied. First, such strategies may serve to entrench smoking by creating a sense of powerlessness in people’s ability to quit. Secondly, they may serve to push smoking into the home – ironically, the environment where the health effects of secondhand smoke exposure are greatest (USDHHS 2006).

In light of the growing concentration of smoking amongst those on the lowest rungs of the social ladder, it is also essential that the class-based consequences of denormalisation receive further consideration. Ultimately, policy makers need to ask urgent moral and practical questions about how society may promote human welfare while attending to the needs of the most disadvantaged and vulnerable groups (Powers and Faden 2006, Baylis et al. 2009). Otherwise, tobacco control policy runs the risk of actively contributing to the very health inequalities it seeks to eradicate.

Footnotes
  • 1

     However, although a reduction in smoking prevalence is a commonly touted benefit of location restrictions on smoking, as Bell and McCullough have argued elsewhere (Bell et al. 2009), the current evidence regarding their impact on smoking prevalence is inconclusive. Indeed, it is likely that such restrictions have uneven effects across the population.

  • 2

     The adoption of tobacco denormalisation strategies by municipal and provincial governments in Vancouver (and in the province) poses a striking contrast to the strong support offered for harm reduction approaches to illicit drug use, where public health officials have argued that de-stigmatising illicit drug use is crucial for encouraging timely access to healthcare, improving health status among people with addictions, and protecting the public from negative health and societal consequences associated with illicit substance use (MacPherson 2001, Ministry of Health 2005, Reist et al. 2004).

  • 3

     The cost effectiveness of ‘deputising’ lay citizens as agents of enforcement has not been lost on policy makers and is highlighted as an explicit benefit of denormalisation in the Canadian tobacco control strategy (Steering Committee of the National Strategy to Reduce Tobacco Use in Canada 1999: 25), which states that such policies ‘can help ensure that people behave in appropriate ways—including making efforts to quit—without the need for a lot of policing or enforcement’.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. The study
  5. ‘Every space is claimed’: smokers’ views on denormalisation strategies
  6. Smoking as a stigmatised identity
  7. Impacts of denormalisation policies
  8. Conclusion and implications
  9. Acknowledgements
  10. References

This research was funded by a seed grant from the Ethics Office of the Canadian Institutes of Health Research titled ‘Rights, risks and smoking: How denormalisation mediates patient-provider interactions in primary care settings’. We would like to acknowledge the contribution of our fellow co-investigator on this study, Michele Bowers, in helping to develop the coding framework for the interview material. Ethical approval was obtained from the University of British Columbia Research Ethics Board (H08-01170-A003) prior to commencing this study.

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  2. Abstract
  3. Introduction
  4. The study
  5. ‘Every space is claimed’: smokers’ views on denormalisation strategies
  6. Smoking as a stigmatised identity
  7. Impacts of denormalisation policies
  8. Conclusion and implications
  9. Acknowledgements
  10. References
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