Aveneu Park, Starling, Australia

As Health, Education, and Welfare, 1964, pg.

As early as the 1960’s, we understood the causal connection between smoking and various cancers. A committee formed to review a number of studies about smoking and health concluded: “In view of the continuing and mounting evidence from many sources, it is the judgment of the Committee that cigarette smoking contributes substantially to mortality from certain specific diseases and to the overall death rate” (U.S. Department of Health, Education, and Welfare, 1964, pg. 31). Public health efforts were initiated to reduce smoking by decreasing the social acceptability of the behavior (Alamar & Glantz, 2006; Bell, Salmon, Bowers, Bell, & McCullough, 2010). While these efforts have been successful at reducing the rates of smoking, they may have also increased stigma surrounding smoking (Chapple et al., 2004; Stuber et al., 2008). Along with anti-smoking media campaigns that attribute responsibility to the smoker (Leveälahti, Tishelman, & Öhlén, 2007), limited research funds, advocacy efforts, and support groups for patients with lung cancer may also contribute to feelings of stigma (Knapp-Oliver & Moyer, 2012; Siminoff, Wilson-Genderson, & Baker, 2010).Stigmatization is the process of discrediting or devaluing an individual because of a personal attribute or behavior considered socially undesirable because it goes against societal “norms” (Goffman, 2009). These attributes are generally related to a personal characteristic or diagnosis of a medical condition that is identified by society to be deviant (Goffman, 2009). In the case of lung cancer, the strong association between smoking and a cancer diagnosis has lead patients with lung cancer to feel stigmatized (Chapple et al., 2004; Sun, Schiller, & Gazdar, 2007). Stigmatized individuals face stereotyping, status loss, and discrimination (Link & Phelan, 2001), which can have harmful implications including reduced self-worth and poor health outcomes (Carter-Harris et al., 2014; Conlon, Gilbert, Jones, & Aldredge, 2010). Interactions that reinforce negative beliefs may increase self-prejudice and self-discrimination among stigmatized individuals.Gerhard Falk (2001), identified two types of stigma: 1) existential stigma, and 2) achieved stigma. Conditions that the person did not choose or have little control over fall under existential stigma (i.e. age), whereas conditions in which a person somehow contributed to their condition fall under achieved stigma (i.e. addiction). Achieved stigma is often attributed to a lung cancer diagnosis because the general perception is that the patient contributed to their condition through poor habits such as smoking (Chapple et al., 2004; Falk, 2001). Individuals that are perceived to have a self-inflicted condition such as lung cancer (e.g. achieved stigma), may face more stigma than individuals with a condition of an uncontrollable origin such as breast cancer (e.g. existential stigma). Conditions associated with highest levels of stigma are described as self-inflicted, incurable, not well-understood, and not easily obscured (Falk, 2001; Goffman, 2009), all of which can apply to a lung cancer diagnosis. As a result, patients with lung cancer are often perceived as responsible for their diagnosis and therefore may experience increased stigma (Stuber et al., 2008).Patients with lung cancer report feeling stigmatized, regardless of their smoking history (current, former, or never smokers) (Chapple et al., 2004; Sun et al., 2007). MORE citations about rates of feeling stigmatized, etc…Stigma contributes to negative health effects such as depression, anxiety, and shame (Brown Johnson et al., 2014; Cataldo et al., 2012), all of which may negatively impact patient well-being and treatment adherence (Carter-Harris et al., 2014; Conlon et al., 2010). Stigmatized individuals report poorer social networks and quality of life (Chapple et al., 2004; Raleigh, 2010). As the hazards of smoking became more apparent in the 1960’s, public health programs to reduce smoking may have had the unintended effect of creating a stigma around smoking and health issues (Alamar & Glantz, 2006; Gilpin, Lee, & Pierce, 2004). Because smoking remains a primary risk factor for developing lung cancer, those diagnosed are often held accountable for the disease (Stuber et al., 2008). Stigma is associated with delays in seeking health care (Angela M. Tod, Craven, & Allmark, 2008), reduced well-being (Brown Johnson et al., 2014; Cataldo & Brodsky, 2013), and challenges to personal identity (Fife & Wright, 2000).The historical context of the stigma surrounding smoking and lung cancer provides a deeper understanding of the internal processes at work for both physicians and patients during lung cancer appointments. Stigma theory suggests that because patients with lung cancer are stigmatized by society, both physicians and patients may be entering the appointment with preconceived ideas about the role of smoking in relation to the disease. Therefore, because smoking is a source of stigma for patients with lung cancer, physicians should approach the discussion of this topic sensitively. 

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