Do your benefits materials refer to smoking as a “habit” or a “lifestyle behavior”? Does your tobacco cessation program penalize people who smoke if they are not able to quit? Are you thinking of expanding your company’s smoke-free policy to make it “smoker free”? Is your approach to help people who smoke simply a check-the-box?
If you answered yes to any of these questions, chances are your approach to benefits design is being strongly influenced by smoking-related stigma.
Understanding what smoking-related stigma is, how it has come about, and the impact it has on employees who smoke can help you make better, evidence-based, compassionate benefits decisions.
What is smoking-related stigma?
First, let’s get on the same page about what stigma is and how it operates when it comes to people who smoke. Stigma has been defined as “the negative labels, pejorative assessments, social distancing and discrimination that occur when individuals deviate from group norms.”
With smoking rates at roughly 14%, not smoking has clearly become normative in the U.S. This is one of the greatest public health successes that has occurred in this country. But it means that the 1 in 7 people who do smoke deviate from this group norm. This is where smoking-related stigma comes into play.
- Negative labels? Check. Smoking is commonly—though erroneously—referred to as a “habit” or a “lifestyle behavior.” The implication is that people who smoke choose to engage in a behavior that they should be able to overcome with motivation and willpower, or that they’ve chosen a dangerous lifestyle even though they “should know better.” It may be tempting to dismiss these kinds of negative labels as simply semantics, but research has shown that language matters. Using person-first language like “people who smoke” instead of “smokers” acknowledges the tenacity of this disease, conveys dignity and greater respect, and can reduce smoking-related stigma.
- Pejorative assessments? Check. People who smoke are often perceived as having negative personality and social traits. They are also perceived negatively in terms of smoking-specific characteristics, with non-smokers assuming universally low levels of motivation to quit and high levels of nicotine dependence among people who smoke. These aren’t silent biases either: research has shown that these negative perceptions influence attitudes about people who smoke, which in turn influence non-smokers’ willingness to interact with people who smoke.
- Social distancing? Check. Clean indoor air laws protect everyone in the workplace and, technically, are imposed on the act of smoking. In practice, however, they have the effect of decreased social standing among people who smoke compared to those who don’t, forcing them outdoors, often to the back alley or the far corners of a workplace to huddle around a smelly receptacle to cope with their addiction.
- Discrimination? Check. Smoking is more common among those with lower levels of education and income, and those with mental health disorders. Combine this with the fact that these subgroups are already at higher risk of discrimination, and smoking-related stigma becomes another assault on top of well-established challenges.
Smoking-related stigma negatively impacts those who smoke and their ability to quit
People who smoke are often acutely aware of the negative stereotypes that others have about them. Many people who use tobacco feel ostracized and judged based on their smoking status, and are aware of high levels of family disapproval and the general social unacceptability of smoking.
Some studies have found that agreement with these stereotypes among people who smoke can lead to smoking cessation, decreased risk of lapse or relapse, and increased intentions to quit. However, the evidence is clear that this kind of self-stigma is much more likely to create negative consequences, such as loss of self-esteem and greater difficulty quitting.
The insidious ways that smoking-related stigma influences benefits design
When smoking-related stigma comes into the workplace or benefits design, nobody wins. Not only do people who smoke feel like they must hide their addiction, but they also struggle with the effects of stigma.
For example, there are 21 states that do not offer employment protection to tobacco users, allowing employers to refuse to hire people who smoke.
Unsurprisingly, people who smoke have a harder time getting hired. For example, the chances of getting a job within a year is reduced by 24% for unemployed job seekers who smoke compared to non-smokers, even when other factors like criminal history are considered.
And even with a job, the stigma still carries through, as people who smoke earn 20% less compared to non-smokers.
For those who work in HR or product design with health plans, it can be easy to fall into the trap of stigmatizing people who smoke, and that can lead to cessation strategies that are punitive rather than supportive. For instance, some organizations use harsh penalties, which can deepen the stigma even more.
Addressing smoking-related stigma
Stigma associated with many mental health conditions like depression is now a well-recognized issue. By acknowledging this stigma, it has allowed considerable progress to be made. Unfortunately, the same progress has not been made in reducing the stigma of substance use disorders like nicotine addiction.
- Consider what assumptions you may hold about people who smoke. Health and wellness professionals are not immune to assumptions about willpower and personal responsibility when it comes to tobacco use. Reflect on your own views. What labels come to mind when you think about people who smoke? What assumptions do you hold about their behavior?
- Acknowledge tobacco use as an addiction. Nicotine is highly addictive and alters the brain circuitry involved in self-regulation and reward processing, much like cocaine and heroin do. Tobacco use disorder is a formal medical diagnosis, characterized by physical dependence, impaired control, and social impairment, among other symptoms. Though not all tobacco use results in tobacco use disorder, any tobacco use has risks and warrants treatment.
- Provide supportive resources to help people out of addiction. Employers and health plans can benefit from reduced smoking prevalence by making comprehensive, compassionate, and easy-to-access treatment readily available to help people break free from tobacco addiction. Less than 1 in 10 people who smoke are able to quit successfully without assistance.
Quit smoking medication combined with behavioral treatment—including social support—increases the chances of success more than twofold and is one of the most cost-effective medical treatments available. Unique to digital interventions such as text messaging is their ability to provide discreet, real-time support that may help people from disadvantaged groups overcome the stigma they face while trying to quit.
- Structure wellness programs in line with these principles. Making people who smoke feel less worthy or shaming them doesn’t work. Use of deposit or “commitment” contracts, where participants put some of their own money at risk and recoup it only if they are successful in changing their behavior, have lower abstinence rates than rewards-based programs. Plus, significantly fewer tobacco users are willing to engage in a quit program that uses this approach. There is good evidence that the best way to help most individuals successfully overcome tobacco addiction is a rewards-based program.
Get started today
A proven, evidence-based resource like the EX Program gives employees and members the compassionate accountability they need to overcome this tenacious addiction and quit for good. See our program page to learn more or contact us to see a demo today.
For ideas on how to engage more tobacco users in a quit journey, I recommend downloading, “4 Ways to Increase Engagement in Tobacco Cessation.”