Does Shunning Smokers Help Them Quit?

You've seen them: the huddled masses standing outside office doorways, in parking lots, on train platforms, cigarettes in hand, taking that last puff before going into one of the growing number of no-smoking zones in America. But dedicated smokers don't just brave the elements; increasingly, they also have to face the scornful looks of passers-by. It's no wonder they're starting to feel like social pariahs. But it turns out that those disdainful glares may be motivating some smokers to quit.

In a study published in the May 22 issue of the New England Journal of Medicine, researchers from Harvard University and the University of California, San Diego, looked at the social networks of 12,067 people who participated in the Framingham Heart Study between 1971 and 2003. They found that smokers were far more likely to stop puffing if their spouses, siblings and friends did so. A person's chances of smoking decreased by 67 percent if a spouse kicked the habit, by 36 percent if a friend did, by 34 percent if a co-worker in a small company did, and by 25 percent if a sibling did.

Though smoking still contributes to the deaths of 435,000 American a year, the number of smokers in the United States has been dropping over the past four decades. In 1965 42.4 percent of American adults smoked. Today it's 20.8 percent. It's impossible to say what has inspired the drop: the increased publicity of bad health effects, imposition of hefty taxes, restrictions on where you can smoke, or social stigma that has been attached to the habit.

To find out more about the so-called "pariah effect" and how it has changed smoking habits, NEWSWEEK's Karen Springen talked with Dr. Steven Schroeder, head of the Smoking Cessation Leadership Center at the University of California, San Francisco, and author of an editorial accompanying the new study. Excerpts:

NEWSWEEK: So is the pariah effect a good thing?
Dr. Steven Schroeder:
To the extent we're influenced by what other people think of us, and smoking is seen as a negative personal behavior, there will be more of an incentive for smokers to quit and less of an incentive for young people to start smoking.

What, if anything, is bad about the pariah effect?
Most smokers want to quit, and if it were easy they'd want to do it. It's very hard to quit because, to some extent, their brains have been changed because of decisions they made as young people. They've become nicotine addicts. They're already laboring under this habit that is injurious to their health, which most of them know, and yet they can't quit. They already feel bad, and if you heap scorn on that, they're going to feel worse. That's the twin sides of this issue.

In your editorial you suggest that the strategy of "love the smoker, hate the smoke" might help smokers quit while avoiding stigmatization.
It's directed not only at smokers but at their family, their loved ones, their friends. As the number of smokers declines, though it's still a large number, many people don't know many smokers. So when they see a smoker they tend to make a judgment—especially doctors, pharmacists, dentists, who have very low smoking rates. My message in this medical journal is, Don't be dismissive. Have compassion for the smoker, even if you want to have that smoker quit.

The pariah effect extends to many parts of life, right?
When you go on these dating services, apparently one of the big things is no smokers. And college roommates—many dorms are smoke free, but there's a check: "Do you smoke?" One of the worst things for a nonsmoker is to be roomed with a smoker. It's intrusive in our daily lives now. Some landlords won't rent to smokers … If you're not able to quit smoking, you run the risk of having a constricted social and professional life … When you go to restaurants you may not be able to smoke, or you may sit at a designated table. It's a daily reminder that you're different, and that you have a habit that most people don't respect.

You mention that many smokers have substance abuse issues or mental health problems. How does feeling like an outcast affect them?
In my parents' era smoking was what everybody did. And now, in many parts of the country, it's a behavior that's shunned. Though smoking used to be equally distributed among all classes, now it's disproportionately a habit among people with lower class, lower education, less income and people with mental illness and/or problems with substance abuse, like alcohol and illegal drugs. For those people, then, it's a double stigma. It's already a stigma having to cope with chronic mental illness and/or drug use. Smoking is a detectable habit. People can see you smoking, and also they can smell it.

I feel very compassionate. I don't want people to make the association, when they see someone smoking, "bad person" and think that person must really want to be smoking. What you do want them to think is, "This person must find it extremely hard to quit. They know how bad it is for them and for others." One of the reasons that smoking has become such a socially unacceptable habit is there's definitive evidence, though it's contested by the tobacco industry, that secondhand smoke is harmful and causes, according to the CDC [Centers for Disease Control], about 50,000 of the 435,000 annual deaths from smoking in the United States alone.

Is nicotine the most difficult substance to quit?
People who have been successfully able to quit alcohol, heroin and cocaine—many of them can't quit smoking. They're ex-addicts, they're ex-alcoholics, but they're smokers. Which is, again, why you should have real compassion.

Why are smokers much more likely to quit if their spouses quit?
It's really hard for you to quit if the person you're living with is smoking. It's just a constant reminder of what you've lost.

Why are nonsmoking co-workers influential in small companies but not big ones?
My sense is that if it's a small firm you know everybody. But at a big firm you probably don't. The smokers probably hang with smokers.

So the smokers at big companies don't feel as ostracized?

Kids often give their smoking parents grief today, right?
They give them lectures. How hard must that be to have your kids scoffing at you, and you know you should quit. There's a real social burden to smoking these days. It's one of the reasons smokers who work together like to go out and have these breaks.

How will the idea that smokers are social outcasts affect kids?
The social issues are much more dominant for kids than concern about health. They all think they're going to live until they're 120.

So if they think they'll be pariahs they won't smoke?
That's right. You'll notice the advertisements from the industry are to show that smoking is cool, or the act of being a rebel. Don't be like your parents, smoke.

What makes people quit besides feeling shunned?
One is price sensitivity. It's been clearly shown that raising the cost of cigarettes discourages people from starting. It makes them want to quit, and if they can't quit they'll smoke less. The second major influence is smoke-free buildings. If you're working on the 30th floor of a building, and you have to go out for your smoke break, you have to get your coat and your purse, push the down button, then you've got to do all that again. You're gone a long time. The economic pressures from the taxes, and the social pressure from the clean indoor air movement have contributed to the lower smoking rate. Smoking is less common, and that makes it more unacceptable.

Are glamorous depictions of smoking in movies and ads counteracting the pariah effect?
The rate of smoking has gone way down. It's about 20 percent now. Why hasn't the rate of smoking in movies gone down? There are different theories for that. One theory is that the tobacco industry has very cleverly manipulated the people in the movies or the writers. They deny that. The second theory is that certain very prominent movie stars themselves smoke, so they insist smoking be written into their roles. The third one is that it's writer's freedom. If the character is unsavory, they may have them smoke to show that. Or it's a wonderful prop.

Are we exporting the problem to Eastern Europe and Asia?
It's not uncommon to find male smoking rates in Asia at 60 to 70 percent and for men in the former Iron Curtain [countries] at 40 to 50 percent. In many of those countries doctors have high smoking rates. In the United States it's 1 percent. The tobacco industry in this country is fighting a rear-guard action. But they see all these overseas markets, and that's where the future profits are.

So over there the pariah effect is a ways off?
There are four different stages. Stage one, where the smoking rates are low. Stage two, in the Eastern European countries and men in Asia, is when the rates really go up, as it was in the United States in the '30s, '40s and '50s. Stage three is where we are now, where it's coming down. And stage four is maybe like Singapore or like doctors in the United States, where we're on our way to having very, very low rates.

Why is Singapore different from other Asian countries?
The government there rules with an iron hand, and it's decided smoking is bad.

What about other countries?
In the Muslim countries, some of the Asian countries, you're a pariah if you smoke and you're a woman because of stereotypes of the women's role. In some Asian countries there are social pressures to smoke. If you're a man, and you're a businessman, it's polite to hand them a business card and a cigarette. Ireland is a smoke-free country. If you go to a pub and … you want to smoke, you've got to go outside. It's the triumph of the science over social norms.

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