Framing responsibility: coverage of lung cancer among smokers and non-smokers in Australian television news
Prof Simon Chapman, School of Public Health, University of Sydney 2006, Australia. Fax: (02) 9036 9019; e-mail: email@example.com
Objective: To analyse news portrayals of lung cancer and associated inferences about responsibility in Australian television news.Methods: Analysis of television news reports, broadcast on Sydney's five free-to-air television channels between 2 May 2005 and 31 August 2009, for all statements pertaining to lung cancer.
Results: Of 2,042 reports mentioning any cancer, 45 made reference to lung cancer, and 28 (62%) referred to diagnoses of lung cancer in non-smokers. Of 157 statements in these reports, 107 (68%) noted that the person featured was a non-smoker. Non-smokers were portrayed sympathetically and as tragic victims, implying they were not responsible for their condition, the sub-text being that smokers are responsible for theirs.
Conclusions: Television news portrays non-smokers with lung cancer with considerable sympathy. Conversely, smokers are implicitly and occasionally explicitly depicted as responsible for their disease.
Implications: The marginalisation of tobacco caused lung cancer in news, together with sympathetic reporting of lung cancer in non-smokers may contribute to stigma surrounding smoking caused disease that may promote delay in seeking treatment, and de-emphasise the role of the tobacco industry's decades-long smoker reassurance program in promoting smoking.
Lung cancer is the leading cause of cancer death both in Australia and globally, accounting for an estimated 1.35 million annual deaths,1 yet it has been recently described as an “unfashionable”2 cancer. In Australia, lung cancer ranks fifth among all cancers in news coverage, well behind breast, prostate, skin and brain cancers3 and well below that which would be predicted if news coverage paralleled cancer death rates and person years of life lost.
This neglect may reflect the association of lung cancer and smoking, which accounts for approximately 80% of diagnoses.1 For decades, the tobacco industry has argued,4–6 and many in the community have agreed that smoking is an entirely individual choice, owing little or nothing to industry marketing and cultural factors reinforced and initiated by the tobacco industry. The prevalence of this view has contributed to perceptions that lung cancer is a self-inflicted disease “tainted by smoking”7 or a moral punishment.8 Such attitudes can stigmatise smokers9–12 and those diagnosed13–15 and diminish public sympathy for those with the disease.16–17
Lung cancer ranks high as a cancer characterised by delayed diagnosis.18 Individuals contracting a disease for which they are held responsible may experience embarrassment, delay seeking health care, and be less likely to become involved in advocacy or support groups aimed at fostering greater support for and understanding of their condition.19 Such reactions have been observed among lung cancer patients who have reported feeling especially stigmatised “because the disease is so strongly associated with smoking”,13 and having concealed their illness, feeling “unworthy” of medical treatment20 and delayed seeking treatment. This situation may be compounded by the dearth of support groups similar to those that exist for many other cancers. This anomaly may reflect poor lung cancer survival times, but may also be because of the stigmatised nature of the disease.7,21–22
Media reports have also occurred about professional debates over whether smokers should be accorded lower priority in surgical waiting lists23–24 because of expressed concerns about poorer prognosis and arguments that their decisions to smoke contribute to their condition. These debates have not occurred with any prominence about other conditions with lifestyle components like obesity or alcohol-related trauma. Public debate about whether sick smokers deserve treatment would hardly make such patients feel their problems attracted much sympathy.
Importantly, lung cancer also occurs in those who have stopped smoking, sometimes decades before the onset of symptoms,13 and in others who have never smoked, having contracted it via exposure to second-hand smoke (SHS) or because of genetic, occupational or idiopathic factors. Never-smokers may account for up to 15% of lung cancers in men and 53% in women globally (approximately 25% of all diagnoses overall) constituting a sub-category that would rank as the seventh leading cause of cancer death.25 The dominant framing26 of smoking as a volitional, self-destructive activity also obscures related considerations including reduction of agency caused by addiction, the near universal experience of regret among smokers,27 millions of annual unsuccessful quit attempts28 and the historic role of the tobacco industry in reassuring smokers about health risks.29–30
The news media is the leading source of public information on health issues,31 and a key influence on health policy formulation,32 but its coverage can reinforce and distort perceptions of key issues33 and contribute to stigmatisation of health problems.34 Media coverage of cancer can disseminate important primary and secondary prevention messages,35 but also create a sense of inevitability of contracting the disease,36 and accentuate individual lifestyle risks over potential social and environmental causes.37
Limited literature exists on media coverage of stigma and smoking-related illness, although analyses of two smoking-related compensation claims in Australia offer some insight. A 2003 study of print media coverage of a high profile lawsuit brought by a terminally ill smoker against a leading cigarette manufacturer found that 35% of reports contained statements holding the plaintiff responsible for her predicament.16 In contrast, reportage of a case involving a non-smoking woman who contracted laryngeal cancer via second hand smoke (SHS) exposure at her workplace focused on the need to protect individuals from such conditions and the injustice involved.38
Previous research on cancer coverage on Australian television, by far the country's most popular mass communication medium,39 demonstrates that lung cancer is markedly under-reported on television news relative to other forms of the disease in terms of incidence and mortality.3 The aim of our analysis in this paper is to explore whether existing coverage is consonant with, and therefore contributory to, prevalent attitudes that hold smokers responsible for their illness.
Box 1: Categories of statements
Incidence: references to the number of new cases of lung cancer, and any demographic characteristics of these cases.
Celebrity cases: any famous or well-known person, including family members of such persons.
Treatment: any statement about treatment modalities, success rates, access or cost.
Prevention: causes and risk factors for lung cancer, including genetic factors.
Profile of lung cancer: any mention of the experience of having lung cancer, or efforts to give it (and research into it) a higher public profile.
Diagnosis: statements about diagnosing or screening for lung cancer.
Regulation and control: statements about controlling smoking which explicitly referred to lung cancer.
All news, current affairs and infotainment items (entertainment programs focused on information such as The Biggest Loser) broadcast on five Sydney free-to-air television channels since May 2005 have been electronically recorded and classified40 as part of the Australian Health News Research Collaboration41 project, which monitors all television coverage of health issues broadcast from Sydney's five free-to-air channels. Data capture, classification, coding and inter-coder reliability testing protocols for this database are described in detail in a methods paper.42
Author SH digitised and coded 2,042 reports on any aspect of cancer broadcast between 2 May 2005 and 31 August 2009 (see http://tobacco.health.usyd.edu.au/share/TV.xls). Each report was coded for specific cancer mentioned, with 45 explicitly mentioning lung cancer. Author RM validated all these (100% concordance) and categorised all (n=157) direct or indirect (“Dr X said …”) statements made by, or attributed to, news actors (patients, family members, clinicians) or media personnel referring to any aspect of lung cancer into seven broad content headings based on the predominant focus of the news item in which they appeared (see Box 1). Any explicit statements about the smoking status of individuals with lung cancer were also noted (Table 1).
Table 1. Focus of statements in 45 television reports mentioning lung cancer.
|Incidence: primarily non-smoking women||42 (27%)||36 (86%)||31 (86%)|
|Celebrity cases: Dana Reeves’ diagnosis and death||33 (21 %)||24 (73%)||24 (100%)|
|Treatment: poor prognosis; government funding||33 (21 %)||9 (27%)||0 (0%)|
|Prevention: risks /causes including genetic disposition to smoke||18 (11 %)||16 (89%)||3 (19%)|
|Profile of lung cancer: stigma; support; fund raising||12 (8%)||9 (75%)||9 (100%)|
|Diagnosis: new methods; current situation||12 (8 %)||6 (50%)||0 (0%)|
|Regulation and control: reports on tobacco control policy referring specifically to lung cancer||7 (4 %)||7 (100 %)||2 (28%)|
|Total||157 (100%)||107 (68%)||68 (63%)|
Of 20,305 reports on any aspect of health or medicine broadcast on Australian television news during the study period, 2,042 (10%) mentioned any form of cancer, and 45 (2% of all cancer-related items) referred to lung cancer, the leading cause of cancer death. Analysis of these 45 reports yielded 157 relevant statements, almost two-thirds (n=107, 68%) of which referred directly to the smoking status of identified individuals with lung cancer (column 3, Table 1). Of these, 68 (63%) noted that the person with lung cancer was not a smoker.
Statements on incidence (n=42) represented more than one-quarter (27%) of the 157 statements made on lung cancer, and were dominated (n=27, 64%) by news that lung cancer was about to become the leading cause of cancer death among Australian women. Of these 27 statements, 22 (81%) referred specifically to lung cancer among non-smokers, described in one report as “tragic victims of the fact that they have a disease that is associated with smoking”.43 A 30-year-old woman interviewee was introduced as a non-smoker by a breakfast news host who observed, “you can imagine it came as a complete shock when she was diagnosed with lung cancer”,44 while the description of another non-smoking woman with the disease noted that “although she never smoked, the vast majority of women with lung cancer have.”45
A further five statements referred to a former smoker who had contracted lung cancer. Three others referred to lung cancer incidence among non-smokers and the remainder focused on related statistical reports.
All but one of the 33 statements in this category occurred in reports of Dana Reeves’ August 2005 diagnosis of lung cancer and subsequent death. Three-quarters (n=24) emphasised that she was a non-smoker: “we had that very sad news last week of Dana Reeves, Christopher Reeves’ wife, diagnosed with lung cancer but she's never smoked.”46 Only three statements referred to SHS exposure during her singing career as the probable cause of her illness.
Nearly two-thirds of statements related to treatment, n=21 (63%), and described the poor prognosis of lung cancer due to frequent late diagnoses and the aggressive nature of the disease. Six statements relating to government subsidisation of the chemotherapy drug Alimta for smokers with lung cancer were contained in reports that explicitly contrasted their situation with that facing people diagnosed with the asbestos-related condition mesothelioma, described as a “glaring inequity”.47 Similarly, a 2007 report observed that “many [mesothelioma] patients miss out on subsidised treatment, while others who have the lung disease as a result of smoking receive the subsidised treatment for free”.48 The remaining statements in this category referred to possible new treatments.
Prevention, risk and causes
Risks and causes were the subject of 18 statements. Nine focused on smoking, five on research into genetic disposition to smoking and associated difficulties in quitting, one reflected on possible non-tobacco related causes and three statements on prevention referred to government policy initiatives.
Profile of lung cancer
These 12 statements dealt with the impact of lung cancer's stigma on treatment, support and fundraising, nine (75%) of which (75%) dealt specifically with non-smokers. One recently diagnosed, non-smoking women described it as the “most stigmatised, ignored, underfunded cancer of all”,49 while another expressed frustration, “[w]hen you discover you have it, there is a shocking stigma, there isn't a lot of support out there unfortunately.”50 One health agency official stated that the situation could result in delays in seeking treatment, information and support, and lead patients to “feel they have brought it on themselves”.50
Just over half in this category of statements (n=7) reported on research into new diagnostic methods. The remainder referred to many diagnoses being made when the cancer is at an advanced stage.
Regulation and control
All seven statements in this category were included in reports on proposals to ban smoking in cars.
Smoking is a leading health news focus in Australia,51 ranking 21 out of 237 content areas as the most frequently reported health issue on television.42 Lung cancer, however, is curiously under-reported despite its status as the leading cause of cancer death, and as the most widely recognised and resonant health consequence of smoking.52 It seems plausible that previous journalistic interest in tobacco-related disease may have waned, and that the subject's newsworthiness today lies more in unusual, ‘man bites dog’, news angles.53 While 77% of lung cancer deaths in Australia occur in smokers and former smokers,54 television news focuses predominantly on non-smokers with the disease.
This emphasis on the plight of non-smokers with lung cancer may imply an element of victim-blaming55 directed at smokers with the disease. News reports highlighting apparent unequal access to subsidised treatment for smokers with lung cancer compared to people with mesothelioma carry a clear sub-text of differing responsibility. Framing smokers with lung cancer as blameworthy also distracts from the tobacco industry's decades-long history of smoker reassurance29 that has disingenuously disseminated ‘information’ that lung cancer was caused by air pollution;56 that leading scientists disagreed that smoking was harmful;57 and that nicotine was not addictive.58 The legacy of the industry's campaign is seemingly not restricted to past generations of smokers. As recently as 2003, 45.8% of Australian smokers believed that “smoking is no more risky than lots of things that people do”; 40.6% that “everything causes cancer these days”; and 22.9% that “the medical evidence that smoking is harmful is exaggerated”.59
Smokers plainly retain considerable agency, as attested by the consistency of data on large numbers of smokers quitting unaided, often without much difficulty.60 But many smokers do have considerable difficulty stopping and experience repeated relapse. As many in the community reason that today's smokers are inundated with information on its risks and are therefore making a “rational choice” to smoke,61,62 those who continue to smoke as it becomes even less prevalent in response to policies and high profile campaigns will increasingly be portrayed as ‘having only themselves to blame’. It is perhaps inevitable that those smokers who contract lung cancer will experience ever-diminishing public sympathy. Ironically, as smoking becomes an increasingly disparaged behaviour,63 increasing regulation and initiatives designed to warn the public about its attendant risks may further contribute to this challenge. Findings that graphic ‘quit smoking’ television campaigns, while effective,64 have themselves contributed to the stigma of lung cancer for their portrayal of an inevitable “dreadful death”13 may, for instance, inadvertently add to the stigmatisation of smokers, many of whom may also experience social disapproval due to poverty, low social economic status and race.65
A further consequence is that negative community attitudes towards those seeking justice over misleading and deceptive tobacco industry conduct16 may dissuade potential litigants from pursuing legal action and influence juries should cases go to trial. Efforts by the public health community to emphasise that today's lung cancer patients acquired their nicotine addiction in an era of widespread tobacco industry malfeasance and government inaction may go some way to lessening the stigma of smoking-related lung cancer and making ‘the cancer journey’ for such patients less stressful and alienated.