G Model
ARTICLE IN PRESS
DRUPOL-1368; No. of Pages 3
International Journal of Drug Policy xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo
Editorial
Stigma as a public health tool: Implications for health promotion and citizen involvement
Stigma is a social mechanism by which individuals and groups are discredited; it reduces social status and creates ‘spoiled identities’ (Goffman, 1963). Stigma can operate at an individual and structural level; and be imposed externally or be self-perceived by individuals who apply negative stereotypes to themselves (Link & Phelan, 2001). In the field of substance use, debates around stigma tend to be divided between studies which assess the harms that stigma carries for health and identity, and an alternative body of work that ‘views stigma more benignly, as a form of social control’ (Room, 2005). We argue that if, as the second body of literature suggests, stigmatising measures are adopted widely in the substance use field their deleterious impact risks exacerbating substance use problems, particularly amongst the least well off. Furthermore, the strategy may impede the commitment to empowerment which has been fundamental to health promotion since the publication of the Ottawa Charter in 1986. Stigma as harmful to health The first type of literature has found that external and selfperceived stigma are particularly high amongst those who use illegal substances, are alcohol dependent and those with, often coexisting, mental health problems (Ahern, Stuber, & Galea, 2007; Schomerus, Holzinger, Matschinger, Lucht, & Angermeyer, 2010). Amongst the problems associated with stigma are its association with barriers to people acknowledging difficulties with substance use and entering or remaining in treatment (Radcliffe & Stevens, 2008; Schomerus & Angermeyer, 2008); a negative impact on the self-esteem crucial to wellbeing and recovery (Link & Phelan, 2001); increased likelihood of relapse (Randels & Tracy, 2013); and undermining access to the social support or social capital needed to aid recovery (Room, 2005). Related to such specific concerns is the more general rejection of stigma as an ‘arbitrary and cruel form of social control’ (Burris, 2008, 475). Stigma as a public health tool In a second body of material it has been suggested that using stigma as a public health tool has the capacity to help bring about changes in health behaviour and is thus ethically acceptable (Bayer, 2008; Callahan, 2013). Given the harms that have been found to be associated with stigma in the drugs field this position is perhaps
surprising. However there is evidence that stigma is already used, perhaps inadvertently, in the field of substance use. For example, in the context of alcohol consumption advertisements about ‘binge’ drinking show young people covered in vomit, or being made to recall the embarrassment of their actions the night before. A number of states in the USA (Minnesota and Ohio) have legislation in place that specifically targets individuals and requires drivers convicted of drinking and driving to display licence plates on their vehicles that publicise their offence. As Nussbaum notes, this public shaming of drink drivers not only serves to publicly stigmatise the drinker, but also their family and close contacts (2004). But perhaps the most notorious instance of stigma is the international ‘war on drugs’ that, in effect, stigmatises individuals by means of criminal sanction. The counterproductive effects of this approach (Buchanan & Young, 2000) led directly to the UK Drug Policy Commission to call for the removal of legislation that reinforces stigma (2010). Similarly, legislation has been a key tool in efforts to denormalise smoking, an initiative that operates at an international level, in the policies of the World Health Organization (World Health Organization, 2003), and within particular nation states. This is a strategy to ‘deglamourize’ smoking and to make it socially unacceptable. Drawing on the 1986 Surgeon General’s report, Bayer notes that the majority of states in the US had some form of legislation in place to control smoking by the mid-1980s (Bayer, 2008). This included restrictions on smoking in certain public places, including the workplace for public and private employees (DHHS, 1986). In Scotland smoke-free legislation was enacted in 2005 and in England in 2007. Similar legislation – the impact of which is most evident in crowds gathered to smoke outside bars, offices and other public buildings – was also introduced widely by other countries, including in Australia on a state by state basis, Canada, Ireland and France. Most recently, efforts to denormalise smoking by cultivating negative social attitudes towards it have been extended to the use of E-cigarettes (Benowitz & Goniewicz, 2013; Stimson, Thom, & Costall, 2014). The impact of anti-smoking legislation and the negative social attitudes it helps to create towards smoking and, importantly, towards individual smokers has been presented as a ‘public health triumph. . . turning what had been considered simply a bad habit into reprehensible behaviour’ (Callahan, 2013). However, it is significant that although rates of tobacco smoking have declined amongst some sectors of the population in richer countries, they remain high amongst low socio-economic groups and are increasing amongst low and middle income countries
http://dx.doi.org/10.1016/j.drugpo.2014.04.008 0955-3959/© 2014 Elsevier B.V. All rights reserved.
Please cite this article in press as: Williamson, L., et al. Stigma as a public health tool: Implications for health promotion and citizen involvement. International Journal of Drug Policy (2014), http://dx.doi.org/10.1016/j.drugpo.2014.04.008
G Model DRUPOL-1368; No. of Pages 3
ARTICLE IN PRESS
2
Editorial / International Journal of Drug Policy xxx (2014) xxx–xxx
(Hiscock, Bauld, Amos, & Platt, 2012). Bayer acknowledges, partly as a result of stigmatisation that the ‘social class composition of smokers underwent a dramatic shift downwards’ (2008). The result, he concedes, is that people ‘. . . who are already socially vulnerable are stigmatized and stigmatization adds to their burden’ (2008). Berridge notes that efforts were made to remedy the social gradient in smoking in the United Kingdom by means of taxation from the late 1970s (2007, 206). But significantly for those promoting the use of stigma as a health control measure, such measures, increased rather than eased health inequalities (Berridge, 2007, 254f). Despite such concerns and the alarm created by already socially marginal groups being further undermined, it has been contended that the benefits from stigmatising populations and behaviours may outweigh the costs of (temporarily) increasing the social marginalisation of the least well-off in society (Bayer, 2008). This is because stigma can be seen as a tool to help redress fundamental health inequalities. In such circumstances, Bayer suggests, stigma is not always as ‘brutal’ or dehumanising as it may first appear because of the benefits it might carry. Given the implications of this contradiction for health and wellbeing, it is important that the dichotomous literature on stigma is supplemented by further analysis of the potential consequences and the wider ramifications of stigma for health promotion. Here we use two examples to raise concerns that highlight the importance of reassessing the use of stigma within this broader context, namely: the impact of stigma on health promotion efforts that aim to utilise citizen involvement and social capital to secure sustainable levels of health; and the negative implications of transferring stigma to e-cigarettes, without reassessing the proportionality of utilising stigma in a wider health promotion context.
against discrimination and stigma – there has been little objection to measures that result in stigma in the context of substance use (Bayer, 2008, 467). It may be that those with sufficient social capital found it relatively easy to stop smoking and avoid being publicly shamed or stigmatised. But those in lower socio-economic groups with less social capital may have neither the psycho-social resources to stop smoking, nor to protest against their negative social treatment. This being so, the role of stigma in undermining confidence, trust and capacities to form supportive relationships may prove more costly for community wellbeing than its exponents anticipate. This is because its impacts risk not being restricted to the short-term, but of entrenching passivity in health consumers, rather than encouraging and enabling them to be equal, active participants in their health. Related to this are the ramifications of stigma for the identity and behaviours of groups. In this respect, concerns have been raised that stigma can lock ‘people in deviant roles’ (Stuber, Galea, & Link, 2009). In this way, stigmatizing and dehumanising entrenches or exacerbates inequalities, rather than helping to alleviate them. A different expression of this concern is that in groups with sufficient social capital, stigma can lead those affected to join together against the discrimination and shaming they encounter. Currently, this type of reaction is evident in the move of users of E-cigarettes to rebrand their use of nicotine as ‘vaping’ and to normalise their identity as vapers, rather than the heavily stigmatised ‘smoker’ (Kurutz, 2013).
Proportionality, public health and new challenges Implications for citizen involvement, trust and social capital For Bayer, the factor that determines the acceptability of using stigma is ‘the ends to which power or the exercise of authority is deployed’ (2008, 470). He suggests that the short-term erosion of individual rights can be acceptable because it can lead to greater equality in the longer term. Responses to this position have tended to be based on the competing ethical position that it is inherently wrong to stigmatise people (Burris, 2008). Here we raise concerns over the consequences of the actual and proposed use of stigma in drug policy and its capacity to impede endeavours to cultivate sustainable levels of health based on public empowerment. A central aim of health promotion is to enable citizens to make healthy choices (World Health Organization, 1986); and to support the ‘right and duty’ citizens have ‘to participate individually and collectively in the planning and implementation of their health care’ (World Health Organization, 1978). This approach is informed by evidence that active, empowered communities and individuals with reserves of social capital – that is, being part of their wider community, having shared values and support from reciprocal, trusting relationships – are more resilient and fare better (Putnam, Leonardi, & Nanenetti, 1993). Citizen involvement requires the cultivation of trust within communities, in their involvement with policy makers and service providers, and in the engagement process itself. The denigration of trust, for example, through stigmatisation may be harmful in the long-term and not be easily repaired. Stigma also risks eroding social capital, particularly within groups who are already socially marginalised. This is significant because social capital is an important factor in controlling substance use, recovery and smoking cessation (Åslund & Nilsson, 2013). Interestingly, in his assessment of the acceptability of using stigma to aid health promotion initiatives, Bayer notes that unlike other health issues – such as HIV/AIDS which witnessed a strong protest movement from human rights advocates to protect people
A central principle within public health ethics is proportionality, as Bayer notes (2008, 468). This holds that policies that constrain liberties are only justified if they are proportionate to the harms being controlled and the benefits produced (Childress, Faden, & Gaare, 2002). Assessments of proportionality in a dynamic health context need to be iterative to remain valid. The availability of new products can also alter the legitimacy of assessments of proportionality. This point is particularly pertinent in relation to efforts to extend the stigmatisation of traditional tobacco smoking to electronic cigarettes; a consumer product with a dramatically different risk/benefit ratio and a potential to function as harm reduction devices (Stimson et al., 2014; Stimson and Costall, 2014). It is important to note that electronic cigarettes not only provide a way to manage the harms associated with traditional tobacco smoking (Goniewicz, Hajek, & McRobbie 2014; McAuley, Hope, Zhao, & Babaian, 2012), but they do so without recourse to stigma and other liberty constraints that can undermine the trust and respect which is crucial for citizen engagement. Public health strategies that undermine individuals and communities, particularly those that urgently need to be engaged and brought within the reach of health services, risk having a negative impact on the fundamental aims of contemporary health promotion. For any gains produced by harm reduction measures in the substance use field, and more widely, to be sustainable, it is imperative they are based on sound, resilient foundations. This requires a state-of-the art evidence base. But in liberal democracies – particularly following the turn to citizen involvement – it is also necessary to recognise that policies that move too far from respecting civic voices and consistently upholding equity will struggle to achieve health gains that are durable. Given such concerns, the use of stigma to control substance use urgently requires critical public debate to test its fit with the goals and ethical drivers of health promotion. This debate must include the voices of those who feel the burden of stigma most acutely.
Please cite this article in press as: Williamson, L., et al. Stigma as a public health tool: Implications for health promotion and citizen involvement. International Journal of Drug Policy (2014), http://dx.doi.org/10.1016/j.drugpo.2014.04.008
G Model DRUPOL-1368; No. of Pages 3
ARTICLE IN PRESS Editorial / International Journal of Drug Policy xxx (2014) xxx–xxx
Acknowledgements The ideas in this editorial were first discussed at a workshop in Vienna hosted by Sigmund Freud University in December 2013, and we are grateful for comments from participants including Wim van den Brink, Franca Beccaria, Geoffrey Hunt, Sébastien Tutenges, Virginia Berridge, Julian Strizek, and Ulrike Kobrna. Conflicts of interest statement Laura Williamson: None. Betsy Thom: In the past three years BT has been a member of ICAP research advisory group. She has attended a meeting supported by ICAP (expenses paid) and written a chapter for an ICAP book (honorarium paid). Gerry V. Stimson: GVS was a member of the National Institute for Health Care Excellence group on the development of guidelines on tobacco harm reduction. A company of which GVS is a director received in 2012 a research feasibility grant from an electronic cigarette company developing a new nicotine delivery device. Alfred Uhl: None. References Ahern, J., Stuber, J., & Galea, S. (2007). Stigma, discrimination and the health of illicit drug users. Drug and Alcohol Dependence, 88, 188–196. Åslund, C., & Nilsson, K. (2013). Social capital in relation to alcohol consumption, smoking, and illicit drug use among adolescents: A cross-sectional study in Sweden. International Journal for Equity in Health, 12, 33. Bayer, R. (2008). Stigma and the ethics of public health: Not can we but should we. Social Science and Medicine, 67, 463–472. Benowitz, N., & Goniewicz. (2013). The regulatory challenge of electronic cigarettes. Journal of the American Medical Association, 10(7), 685–686. Berridge, V. (2007). Marketing health: Smoking and the discourse of public health in Britain 1945–2000. Oxford: Oxford University Press. Buchanan, J., & Young, L. (2000). The war in drugs – A war in drug users. Drugs: Education, Prevention and Policy, 7(4), 409–422. Burris, S. (2008). Stigma, ethics and policy: A Commentary on Bayer’s “Stigma and the ethics of public health: Not can we but should we”. Social Science and Medicine, 67, 437–475. Callahan, D. (2013). Obesity chasing an elusive epidemic. In Hastings Center Report, 43, no. 1. Childress, J. F., Faden, R. R., Gaare, R. D., Gostin, L. O., Kahn, J., Bonnie, R. J., et al. (2002). Public health ethics: Mapping the terrain. Journal of Law, Medicine and Ethics, 30, 169–177. Department of Health Human Services. (1986). The health consequences of involuntary smoking. Rockville, Maryland: DHHS. Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Prentice-Hall. Goniewicz, M., Hajek, P., & McRobbie, H. (2014). Nicotine content of electronic cigarettes, its release in vapour and its consistency across batches: regulatory implications. Addiction, 109(3), 500–507. Hiscock, R., Bauld, L., Amos, A., & Platt, S. (2012). Smoking and socioeconomic status in England: The rise of the never smoker and the disadvantaged smoker. Journal of Public Health, 34(3), 390–396. Kurutz, S. (2013). Smoking is back, without stigma. In New York Times. Link, B., & Phelan, J. (2001). Conceptualising stigma. Annual Review of Sociology, 27, 363–385.
3
McAuley, T., Hope, P., Zhao, J., & Babaian, S. (2012). Comparison of the effects of ecigarette vapour and cigarette smoke on indoor air quality. Inhalation Toxicology, 24(12), 850–857. Nussbaum, M. C. (2004). Hiding from humanity: Disgust, shame and the law. Princeton, NJ: Princeton University Press. Putnam, R., Leonardi, R., & Nanenetti, R. (1993). Making democracy work: Civic traditions in modern Italy. Princeton, NJ: Princeton University Press. Radcliffe, P., & Stevens, A. (2008). Are drug treatment services only for “thieving junkie scumbags”? Drug users and the management of stigmatised identities. Social Science and Medicine, 67, 1065–1073. Randels, D., & Tracy, J. (2013). Nonverbal displays of shame predict relapse and declining health in recovering alcoholics. Clinical Psychological Science, 1(2), 149–155. Room, R. (2005). Stigma, social inequality and alcohol and drug use. Drug and Alcohol Review, 24(2), 143–155. Schomerus, G., & Angermeyer, M. (2008). Stigma and its impact on help-seeking for mental disorders: What do we know? Epidemiologia e Psichiatria Sociale, 17(1), 31–37. Schomerus, G., Holzinger, A., Matschinger, H., Lucht, M., & Angermeyer, M. C. (2010). Public attitudes towards alcohol dependence. Psychiatriche Praxis, 37, 111–118. Stimson, G. V., & Costall, P. J. (2014). UK Public Health Doctors and e-cigarettes – Why this matters. http://nicotinepolicy.net/gerry-stimson/673-uk-public-healthAccessed doctors-and-e-cigarettes-why-this-matters accessed 20 Jan 2014 18.02.14 Stimson, G. V., Thom, B., & Costall, P. (2014). Disruptive innovations and the rise of the E-Cigarette. International Journal of Drugs Policy. Stuber, J., Galea, S., & Link, B. (2009). Stigma and smoking: The consequences of out good intentions. Social Service Review, 83(4), 585–610. UK Drugs Policy Commission. (2010). Getting serious about stigma: The problem with stigmatizing drug users. World Health Organization. (2003). Framework convention of tobacco control. Geneva: WHO. World Health Organization. (1986). The Ottawa charter on health promotion. Geneva: WHO. World Health Organization, 1978, Declaration of Alma-Ata, International Conference on Primary Health Care, Alma-Ata, USSR, 6-12, September 1978.
Laura Williamson a,∗ Betsy Thom b Gerry V. Stimson c Alfred Uhl d a Institute for Applied Health Research, Glasgow Caledonian University, Glasgow G4 0BA, United Kingdom b Drug and Alcohol Research Centre, University of Middlesex c Imperial College London, and London School of Hygiene and Tropical Medicine d Addiction Research and Documentation at the Anton-Proksch-Institute, Graefin Zichy Straße 6, Vienna, Austria ∗ Corresponding
author. Tel.: +44 0141 331 8901. E-mail address: [email protected] (L. Williamson) 12 March 2014
Please cite this article in press as: Williamson, L., et al. Stigma as a public health tool: Implications for health promotion and citizen involvement. International Journal of Drug Policy (2014), http://dx.doi.org/10.1016/j.drugpo.2014.04.008
ARTICLE IN PRESS
DRUPOL-1368; No. of Pages 3
International Journal of Drug Policy xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo
Editorial
Stigma as a public health tool: Implications for health promotion and citizen involvement
Stigma is a social mechanism by which individuals and groups are discredited; it reduces social status and creates ‘spoiled identities’ (Goffman, 1963). Stigma can operate at an individual and structural level; and be imposed externally or be self-perceived by individuals who apply negative stereotypes to themselves (Link & Phelan, 2001). In the field of substance use, debates around stigma tend to be divided between studies which assess the harms that stigma carries for health and identity, and an alternative body of work that ‘views stigma more benignly, as a form of social control’ (Room, 2005). We argue that if, as the second body of literature suggests, stigmatising measures are adopted widely in the substance use field their deleterious impact risks exacerbating substance use problems, particularly amongst the least well off. Furthermore, the strategy may impede the commitment to empowerment which has been fundamental to health promotion since the publication of the Ottawa Charter in 1986. Stigma as harmful to health The first type of literature has found that external and selfperceived stigma are particularly high amongst those who use illegal substances, are alcohol dependent and those with, often coexisting, mental health problems (Ahern, Stuber, & Galea, 2007; Schomerus, Holzinger, Matschinger, Lucht, & Angermeyer, 2010). Amongst the problems associated with stigma are its association with barriers to people acknowledging difficulties with substance use and entering or remaining in treatment (Radcliffe & Stevens, 2008; Schomerus & Angermeyer, 2008); a negative impact on the self-esteem crucial to wellbeing and recovery (Link & Phelan, 2001); increased likelihood of relapse (Randels & Tracy, 2013); and undermining access to the social support or social capital needed to aid recovery (Room, 2005). Related to such specific concerns is the more general rejection of stigma as an ‘arbitrary and cruel form of social control’ (Burris, 2008, 475). Stigma as a public health tool In a second body of material it has been suggested that using stigma as a public health tool has the capacity to help bring about changes in health behaviour and is thus ethically acceptable (Bayer, 2008; Callahan, 2013). Given the harms that have been found to be associated with stigma in the drugs field this position is perhaps
surprising. However there is evidence that stigma is already used, perhaps inadvertently, in the field of substance use. For example, in the context of alcohol consumption advertisements about ‘binge’ drinking show young people covered in vomit, or being made to recall the embarrassment of their actions the night before. A number of states in the USA (Minnesota and Ohio) have legislation in place that specifically targets individuals and requires drivers convicted of drinking and driving to display licence plates on their vehicles that publicise their offence. As Nussbaum notes, this public shaming of drink drivers not only serves to publicly stigmatise the drinker, but also their family and close contacts (2004). But perhaps the most notorious instance of stigma is the international ‘war on drugs’ that, in effect, stigmatises individuals by means of criminal sanction. The counterproductive effects of this approach (Buchanan & Young, 2000) led directly to the UK Drug Policy Commission to call for the removal of legislation that reinforces stigma (2010). Similarly, legislation has been a key tool in efforts to denormalise smoking, an initiative that operates at an international level, in the policies of the World Health Organization (World Health Organization, 2003), and within particular nation states. This is a strategy to ‘deglamourize’ smoking and to make it socially unacceptable. Drawing on the 1986 Surgeon General’s report, Bayer notes that the majority of states in the US had some form of legislation in place to control smoking by the mid-1980s (Bayer, 2008). This included restrictions on smoking in certain public places, including the workplace for public and private employees (DHHS, 1986). In Scotland smoke-free legislation was enacted in 2005 and in England in 2007. Similar legislation – the impact of which is most evident in crowds gathered to smoke outside bars, offices and other public buildings – was also introduced widely by other countries, including in Australia on a state by state basis, Canada, Ireland and France. Most recently, efforts to denormalise smoking by cultivating negative social attitudes towards it have been extended to the use of E-cigarettes (Benowitz & Goniewicz, 2013; Stimson, Thom, & Costall, 2014). The impact of anti-smoking legislation and the negative social attitudes it helps to create towards smoking and, importantly, towards individual smokers has been presented as a ‘public health triumph. . . turning what had been considered simply a bad habit into reprehensible behaviour’ (Callahan, 2013). However, it is significant that although rates of tobacco smoking have declined amongst some sectors of the population in richer countries, they remain high amongst low socio-economic groups and are increasing amongst low and middle income countries
http://dx.doi.org/10.1016/j.drugpo.2014.04.008 0955-3959/© 2014 Elsevier B.V. All rights reserved.
Please cite this article in press as: Williamson, L., et al. Stigma as a public health tool: Implications for health promotion and citizen involvement. International Journal of Drug Policy (2014), http://dx.doi.org/10.1016/j.drugpo.2014.04.008
G Model DRUPOL-1368; No. of Pages 3
ARTICLE IN PRESS
2
Editorial / International Journal of Drug Policy xxx (2014) xxx–xxx
(Hiscock, Bauld, Amos, & Platt, 2012). Bayer acknowledges, partly as a result of stigmatisation that the ‘social class composition of smokers underwent a dramatic shift downwards’ (2008). The result, he concedes, is that people ‘. . . who are already socially vulnerable are stigmatized and stigmatization adds to their burden’ (2008). Berridge notes that efforts were made to remedy the social gradient in smoking in the United Kingdom by means of taxation from the late 1970s (2007, 206). But significantly for those promoting the use of stigma as a health control measure, such measures, increased rather than eased health inequalities (Berridge, 2007, 254f). Despite such concerns and the alarm created by already socially marginal groups being further undermined, it has been contended that the benefits from stigmatising populations and behaviours may outweigh the costs of (temporarily) increasing the social marginalisation of the least well-off in society (Bayer, 2008). This is because stigma can be seen as a tool to help redress fundamental health inequalities. In such circumstances, Bayer suggests, stigma is not always as ‘brutal’ or dehumanising as it may first appear because of the benefits it might carry. Given the implications of this contradiction for health and wellbeing, it is important that the dichotomous literature on stigma is supplemented by further analysis of the potential consequences and the wider ramifications of stigma for health promotion. Here we use two examples to raise concerns that highlight the importance of reassessing the use of stigma within this broader context, namely: the impact of stigma on health promotion efforts that aim to utilise citizen involvement and social capital to secure sustainable levels of health; and the negative implications of transferring stigma to e-cigarettes, without reassessing the proportionality of utilising stigma in a wider health promotion context.
against discrimination and stigma – there has been little objection to measures that result in stigma in the context of substance use (Bayer, 2008, 467). It may be that those with sufficient social capital found it relatively easy to stop smoking and avoid being publicly shamed or stigmatised. But those in lower socio-economic groups with less social capital may have neither the psycho-social resources to stop smoking, nor to protest against their negative social treatment. This being so, the role of stigma in undermining confidence, trust and capacities to form supportive relationships may prove more costly for community wellbeing than its exponents anticipate. This is because its impacts risk not being restricted to the short-term, but of entrenching passivity in health consumers, rather than encouraging and enabling them to be equal, active participants in their health. Related to this are the ramifications of stigma for the identity and behaviours of groups. In this respect, concerns have been raised that stigma can lock ‘people in deviant roles’ (Stuber, Galea, & Link, 2009). In this way, stigmatizing and dehumanising entrenches or exacerbates inequalities, rather than helping to alleviate them. A different expression of this concern is that in groups with sufficient social capital, stigma can lead those affected to join together against the discrimination and shaming they encounter. Currently, this type of reaction is evident in the move of users of E-cigarettes to rebrand their use of nicotine as ‘vaping’ and to normalise their identity as vapers, rather than the heavily stigmatised ‘smoker’ (Kurutz, 2013).
Proportionality, public health and new challenges Implications for citizen involvement, trust and social capital For Bayer, the factor that determines the acceptability of using stigma is ‘the ends to which power or the exercise of authority is deployed’ (2008, 470). He suggests that the short-term erosion of individual rights can be acceptable because it can lead to greater equality in the longer term. Responses to this position have tended to be based on the competing ethical position that it is inherently wrong to stigmatise people (Burris, 2008). Here we raise concerns over the consequences of the actual and proposed use of stigma in drug policy and its capacity to impede endeavours to cultivate sustainable levels of health based on public empowerment. A central aim of health promotion is to enable citizens to make healthy choices (World Health Organization, 1986); and to support the ‘right and duty’ citizens have ‘to participate individually and collectively in the planning and implementation of their health care’ (World Health Organization, 1978). This approach is informed by evidence that active, empowered communities and individuals with reserves of social capital – that is, being part of their wider community, having shared values and support from reciprocal, trusting relationships – are more resilient and fare better (Putnam, Leonardi, & Nanenetti, 1993). Citizen involvement requires the cultivation of trust within communities, in their involvement with policy makers and service providers, and in the engagement process itself. The denigration of trust, for example, through stigmatisation may be harmful in the long-term and not be easily repaired. Stigma also risks eroding social capital, particularly within groups who are already socially marginalised. This is significant because social capital is an important factor in controlling substance use, recovery and smoking cessation (Åslund & Nilsson, 2013). Interestingly, in his assessment of the acceptability of using stigma to aid health promotion initiatives, Bayer notes that unlike other health issues – such as HIV/AIDS which witnessed a strong protest movement from human rights advocates to protect people
A central principle within public health ethics is proportionality, as Bayer notes (2008, 468). This holds that policies that constrain liberties are only justified if they are proportionate to the harms being controlled and the benefits produced (Childress, Faden, & Gaare, 2002). Assessments of proportionality in a dynamic health context need to be iterative to remain valid. The availability of new products can also alter the legitimacy of assessments of proportionality. This point is particularly pertinent in relation to efforts to extend the stigmatisation of traditional tobacco smoking to electronic cigarettes; a consumer product with a dramatically different risk/benefit ratio and a potential to function as harm reduction devices (Stimson et al., 2014; Stimson and Costall, 2014). It is important to note that electronic cigarettes not only provide a way to manage the harms associated with traditional tobacco smoking (Goniewicz, Hajek, & McRobbie 2014; McAuley, Hope, Zhao, & Babaian, 2012), but they do so without recourse to stigma and other liberty constraints that can undermine the trust and respect which is crucial for citizen engagement. Public health strategies that undermine individuals and communities, particularly those that urgently need to be engaged and brought within the reach of health services, risk having a negative impact on the fundamental aims of contemporary health promotion. For any gains produced by harm reduction measures in the substance use field, and more widely, to be sustainable, it is imperative they are based on sound, resilient foundations. This requires a state-of-the art evidence base. But in liberal democracies – particularly following the turn to citizen involvement – it is also necessary to recognise that policies that move too far from respecting civic voices and consistently upholding equity will struggle to achieve health gains that are durable. Given such concerns, the use of stigma to control substance use urgently requires critical public debate to test its fit with the goals and ethical drivers of health promotion. This debate must include the voices of those who feel the burden of stigma most acutely.
Please cite this article in press as: Williamson, L., et al. Stigma as a public health tool: Implications for health promotion and citizen involvement. International Journal of Drug Policy (2014), http://dx.doi.org/10.1016/j.drugpo.2014.04.008
G Model DRUPOL-1368; No. of Pages 3
ARTICLE IN PRESS Editorial / International Journal of Drug Policy xxx (2014) xxx–xxx
Acknowledgements The ideas in this editorial were first discussed at a workshop in Vienna hosted by Sigmund Freud University in December 2013, and we are grateful for comments from participants including Wim van den Brink, Franca Beccaria, Geoffrey Hunt, Sébastien Tutenges, Virginia Berridge, Julian Strizek, and Ulrike Kobrna. Conflicts of interest statement Laura Williamson: None. Betsy Thom: In the past three years BT has been a member of ICAP research advisory group. She has attended a meeting supported by ICAP (expenses paid) and written a chapter for an ICAP book (honorarium paid). Gerry V. Stimson: GVS was a member of the National Institute for Health Care Excellence group on the development of guidelines on tobacco harm reduction. A company of which GVS is a director received in 2012 a research feasibility grant from an electronic cigarette company developing a new nicotine delivery device. Alfred Uhl: None. References Ahern, J., Stuber, J., & Galea, S. (2007). Stigma, discrimination and the health of illicit drug users. Drug and Alcohol Dependence, 88, 188–196. Åslund, C., & Nilsson, K. (2013). Social capital in relation to alcohol consumption, smoking, and illicit drug use among adolescents: A cross-sectional study in Sweden. International Journal for Equity in Health, 12, 33. Bayer, R. (2008). Stigma and the ethics of public health: Not can we but should we. Social Science and Medicine, 67, 463–472. Benowitz, N., & Goniewicz. (2013). The regulatory challenge of electronic cigarettes. Journal of the American Medical Association, 10(7), 685–686. Berridge, V. (2007). Marketing health: Smoking and the discourse of public health in Britain 1945–2000. Oxford: Oxford University Press. Buchanan, J., & Young, L. (2000). The war in drugs – A war in drug users. Drugs: Education, Prevention and Policy, 7(4), 409–422. Burris, S. (2008). Stigma, ethics and policy: A Commentary on Bayer’s “Stigma and the ethics of public health: Not can we but should we”. Social Science and Medicine, 67, 437–475. Callahan, D. (2013). Obesity chasing an elusive epidemic. In Hastings Center Report, 43, no. 1. Childress, J. F., Faden, R. R., Gaare, R. D., Gostin, L. O., Kahn, J., Bonnie, R. J., et al. (2002). Public health ethics: Mapping the terrain. Journal of Law, Medicine and Ethics, 30, 169–177. Department of Health Human Services. (1986). The health consequences of involuntary smoking. Rockville, Maryland: DHHS. Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Prentice-Hall. Goniewicz, M., Hajek, P., & McRobbie, H. (2014). Nicotine content of electronic cigarettes, its release in vapour and its consistency across batches: regulatory implications. Addiction, 109(3), 500–507. Hiscock, R., Bauld, L., Amos, A., & Platt, S. (2012). Smoking and socioeconomic status in England: The rise of the never smoker and the disadvantaged smoker. Journal of Public Health, 34(3), 390–396. Kurutz, S. (2013). Smoking is back, without stigma. In New York Times. Link, B., & Phelan, J. (2001). Conceptualising stigma. Annual Review of Sociology, 27, 363–385.
3
McAuley, T., Hope, P., Zhao, J., & Babaian, S. (2012). Comparison of the effects of ecigarette vapour and cigarette smoke on indoor air quality. Inhalation Toxicology, 24(12), 850–857. Nussbaum, M. C. (2004). Hiding from humanity: Disgust, shame and the law. Princeton, NJ: Princeton University Press. Putnam, R., Leonardi, R., & Nanenetti, R. (1993). Making democracy work: Civic traditions in modern Italy. Princeton, NJ: Princeton University Press. Radcliffe, P., & Stevens, A. (2008). Are drug treatment services only for “thieving junkie scumbags”? Drug users and the management of stigmatised identities. Social Science and Medicine, 67, 1065–1073. Randels, D., & Tracy, J. (2013). Nonverbal displays of shame predict relapse and declining health in recovering alcoholics. Clinical Psychological Science, 1(2), 149–155. Room, R. (2005). Stigma, social inequality and alcohol and drug use. Drug and Alcohol Review, 24(2), 143–155. Schomerus, G., & Angermeyer, M. (2008). Stigma and its impact on help-seeking for mental disorders: What do we know? Epidemiologia e Psichiatria Sociale, 17(1), 31–37. Schomerus, G., Holzinger, A., Matschinger, H., Lucht, M., & Angermeyer, M. C. (2010). Public attitudes towards alcohol dependence. Psychiatriche Praxis, 37, 111–118. Stimson, G. V., & Costall, P. J. (2014). UK Public Health Doctors and e-cigarettes – Why this matters. http://nicotinepolicy.net/gerry-stimson/673-uk-public-healthAccessed doctors-and-e-cigarettes-why-this-matters accessed 20 Jan 2014 18.02.14 Stimson, G. V., Thom, B., & Costall, P. (2014). Disruptive innovations and the rise of the E-Cigarette. International Journal of Drugs Policy. Stuber, J., Galea, S., & Link, B. (2009). Stigma and smoking: The consequences of out good intentions. Social Service Review, 83(4), 585–610. UK Drugs Policy Commission. (2010). Getting serious about stigma: The problem with stigmatizing drug users. World Health Organization. (2003). Framework convention of tobacco control. Geneva: WHO. World Health Organization. (1986). The Ottawa charter on health promotion. Geneva: WHO. World Health Organization, 1978, Declaration of Alma-Ata, International Conference on Primary Health Care, Alma-Ata, USSR, 6-12, September 1978.
Laura Williamson a,∗ Betsy Thom b Gerry V. Stimson c Alfred Uhl d a Institute for Applied Health Research, Glasgow Caledonian University, Glasgow G4 0BA, United Kingdom b Drug and Alcohol Research Centre, University of Middlesex c Imperial College London, and London School of Hygiene and Tropical Medicine d Addiction Research and Documentation at the Anton-Proksch-Institute, Graefin Zichy Straße 6, Vienna, Austria ∗ Corresponding
author. Tel.: +44 0141 331 8901. E-mail address: [email protected] (L. Williamson) 12 March 2014
Please cite this article in press as: Williamson, L., et al. Stigma as a public health tool: Implications for health promotion and citizen involvement. International Journal of Drug Policy (2014), http://dx.doi.org/10.1016/j.drugpo.2014.04.008
