Review of: Cortland CI et al, Addiction 2019;114:1842–1848

Tobacco use is the single most preventable cause of death, disease, and disability in the United States. Among the $50 million the American government spends each year on tobacco cessation efforts, part of that money is spent on public service campaigns that work to shame or stigmatize smoking as an undesirable behavior. This study investigates how the social stereotype threat—creating concern about being judged unfavorably by others—may impact one’s ability to resist the next cigarette.

In this randomized controlled trial, 77 non-treatment-seeking, otherwise healthy adult smokers were recruited from the community and randomized to receive a stereotype threat or a control message after 12 hours of abstinence. Specifically, the stereotype threat group was told that the investigators were interested in “whether non-smokers are superior across all positive traits or only certain types [such as] willpower, laziness, weakness, and responsibility,” bringing to participants’ minds the negative stereotypes of people who smoke. Both the intervention and control groups were given a lighter, an ashtray, some of their favorite cigarettes, and a small monetary reward for delaying smoking during hour-long observation periods.

The investigators did not find any significant difference in time-to-smoke data between the intervention and control groups. However, when the investigators controlled for baseline latency-to-smoke, they discovered that the stereotype threat was associated with lesser latency-to-smoke (hazard ratio 0.50, confidence interval 0.30–0.85). The researchers concluded that the stereotype threat actually functioned as a “smoking-promoting message.”

Major limitations of the study include the short length of the observation period and the simplicity of the stereotype threat, which may not well approximate the complex and multifaceted nature of stereotypes in specific communities and in society at large. Another major limitation is that the control group did not receive a non-threat, smoking-related cue.

CATR’s Take
While it doesn’t readily approximate the complex nature of stereotype or stigma, this study suggests that shaming people may increase their likelihood of lighting up. Although public health messaging that focuses on the harms of smoking can be effective, addiction treatment providers should work to minimize shame and stigma in their patients and in society.