Stigmatising smokers puts social cohesion out of reach

http://www.guardian.co.uk/commentisfree/2012/feb/29/stigmatising-smokers-social-cohesion

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Policies to improve health aim to do just that: to promote everyone's health and wellbeing. Evaluations are set up to capture these positive impacts. Thus policies that encourage us to give up smoking and to eat well are deemed to be effective if they are associated with declines in smoking and increases in fruit and vegetable consumption.

But policies can have negative as well as positive outcomes. These negative side-effects tend to occur off stage, in areas where neither researchers nor policymakers are looking. Unrecognised, they typically go unmeasured – and therefore cannot inform the policy development process.

An important unmeasured effect is stigma: the denigration of individuals and communities whose lifestyles fail to match what is deemed healthy and desirable. Britain's social history is scarred by policies that, pursued in the name of public health, served to intensify discrimination against already-disadvantaged groups. In 19th-century Britain, it was the urban poor – and particularly the Irish migrant community – who bore the brunt of what is called "policy-induced stigma". Their lifestyles were held up to public condemnation, with their perceived lack of personal and domestic hygiene and their drunkenness regarded as the vectors of disease and moral decline.

Can a similar process be seen at work today? In 21st-century Britain, the scourge of infectious disease is fortunately no longer with us. Instead, the big killers are chronic diseases such as coronary heart disease and lung cancer. As in the 19th-century, these diseases take a heavier toll on poorer than richer groups – and it is their lifestyles that are identified as the cause. It is a small step to seeing those who fail to give up smoking and to lose weight as responsible for their ill-health – and those who have never smoked or struggled with their weight as morally and socially superior.

Cigarette smoking provides a window on how these stigmatising effects can come about. Anti-smoking policies have communicated the risks of smoking through information campaigns, pictures on cigarette packets of rotting teeth and diseased lungs and restrictions on smoking in public places. The evidence suggests that these policies have been effective in improving health knowledge and driving down smoking rates. Today, most people are aware of the dangers of smoking, and smoking has shifted from being a majority to a minority habit.

But what was once a lifestyle popular in all social classes is now largely restricted to white, working-class communities. And surveys suggest that moral judgments and class stigma infuse the way many people think about smokers. Non-smokers see smokers as outcasts who are dirty and weak-willed. When asked to describe the typical smoker, they refer to poor council house tenants, the unemployed, teenage mothers and a social underclass.

Smokers are aware of these negative perceptions; they talk about feeling like lepers and being persecuted. They know that smoking – like eating habits, patterns of exercise and drinking habits – mark the boundary between the "rough" and the respectable, and that they are looked down on for habits personified by Frank Gallagher and Vicky Pollard.

Sensitivity to policy-induced stigma would not be hard to build into policy evaluations. Negative impacts could be explicitly anticipated through impact assessments that capture both direct health benefits and indirect social costs. Their starting point should be that social class is coded through behaviours such as smoking and diet. Promoting lifestyles more commonly found in middle-class communities is therefore unlikely to promote social cohesiveness. It risks moving the government's goal of "creating a country which feels like a community" even further out of reach.

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