as Unintended Consequences of Tobacco Control

Jamie S. Ostroff, PhD; Jamie L. Studts, PhD & the Cancer Special Interest Group (SIG)

Behavioral medicine has played a seminal role in the development of multi-level behavior change interventions designed to reduce cancer risk. Most notably, comprehensive, multi-pronged population-level, tobacco control interventions have greatly reduced the appeal and acceptability of smoking, increased smoking cessation, reduced secondhand smoke exposure, and decreased the initiation of cigarette smoking among young people. Behavioral medicine expertise has greatly contributed to many of these tobacco control tools and there is indeed much to celebrate in terms of reducing the population burden of smoking. Although hard-hitting, anti-tobacco, public health campaigns highlighting the health consequences of smoking have undoubtedly helped reduce the health burden of smoking, there is growing recognition of the potential harms of these messages and how it has impacted how society views and treats individuals who have smoked.1 Regardless of their smoking history, the overwhelming majority of patients diagnosed with lung cancer report experiencing stigma often triggered by the ubiquitous question (“Do/Did You Smoke?”) following disclosure of their lung cancer diagnosis to family, friends, co-workers or even healthcare clinicians.2

What is lung cancer stigma?

Lung cancer stigma is defined as the recognition and subsequent devaluation of someone based on their diagnosis of lung cancer. A conceptual model as well as patient-reported tools are available for the measurement of three important facets of lung cancer stigma 3, 4Perceived Stigma, the perception of negative appraisals and devaluation from others (what others think and say); Internalized Stigma, the internalization of these feelings by patients (feelings of shame, guilt, or self-blame); and Constrained Disclosure, avoidance or discomfort in talking about one’s lung cancer with others, usually out of anticipation or fear that one would be met with stigma.

Why does lung cancer stigma matter?

Recent innovations in early detection, treatment, and survivorship have transformed lung cancer care, and have led to improved outcomes for individuals who face high lung cancer risk or who have been diagnosed with lung cancer. However, lung cancer stigma impedes access to these innovations in care and adversely impacts each component of the lung cancer control continuum. 5 Specifically, lung cancer stigma impedes engagement with and utilization of:

  • evidence-based tobacco prevention and treatment
  • high quality lung cancer screening
  • optimal diagnosis and treatment
  • survivorship support and palliative care
  • end-of-life and bereavement care

Lung cancer stigma adversely impacts psychological adaptation to cancer and has been associated with:

  • Depressive symptoms
  • Anxiety
  • Poor quality of life

What are some potential strategies for reducing stigma associated with smoking and other stigmatized health risk behaviors?

  • Words matter! Use person-first and other de-stigmatizing language to reduce microaggressions
  • Appreciate complexity of patient narrative and lived experience
  • Consider gain-framed, empowering, and empathic health behavior change messages
  • Consider systemic factors that exacerbate lung cancer stigma – discrimination, medical mistrust, implicit bias, intersectionality
  • Make empathic communication skills a core competency for all healthcare trainees and practitioners 6
  • Promote partnerships with patients, advocates and marginalized communities
  • Measure stigma as a potential target for psychosocial interventions
  • Develop and test multi-level (patient, clinician and societal) anti-stigma interventions on psychosocial patient outcomes, cancer care delivery, and health policy
  • Become involved with the National Lung Cancer Roundtable’s Lung Cancer Stigma Initiative and confront lung cancer stigma on the societal level

In summary, health behavior change need not have adverse psychosocial consequences. As behavioral medicine researchers, clinicians, and educators, it is imperative for us to develop, evaluate, and disseminate inclusive and equitable health behavior change interventions that promote health lifestyles and maintain dignity, compassion and respect for individuals struggling with behavior change. No Shame, No Blame!


  1. Riley KE, Ulrich MR, Hamann HA, Ostroff JS. Decreasing Smoking but Increasing Stigma? Anti-tobacco Campaigns, Public Health, and Cancer Care. AMA J Ethics. 2017;19(5):475-85. Epub 20170501. doi: 10.1001/journalofethics.2017.19.5.msoc1-1705. PubMed PMID: 28553905; PMCID: PMC5679230.
  2. Ostroff JS, Banerjee SC, Lynch K, Shen MJ, Williamson TJ, Haque N, Riley K, Hamann HA, Rigney M, Park B. Reducing stigma triggered by assessing smoking status among patients diagnosed with lung cancer: De-stigmatizing do and don’t lessons learned from qualitative interviews. PEC Innovation. 2022;1:100025. doi:
  3. Hamann HA, Ostroff JS, Marks EG, Gerber DE, Schiller JH, Lee SJ. Stigma among patients with lung cancer: a patient-reported measurement model. Psychooncology. 2014;23(1):81-92. Epub 20131003. doi: 10.1002/pon.3371. PubMed PMID: 24123664; PMCID: PMC3936675.
  4. Hamann HA, Shen MJ, Thomas AJ, Craddock Lee SJ, Ostroff JS. Development and Preliminary Psychometric Evaluation of a Patient-Reported Outcome Measure for Lung Cancer Stigma: The Lung Cancer Stigma Inventory (LCSI). Stigma Health. 2018;3(3):195-203. Epub 20170406. doi: 10.1037/sah0000089. PubMed PMID: 30393760; PMCID: PMC6208151.
  5. Hamann HA, Ver Hoeve ES, Carter-Harris L, Studts JL, Ostroff JS. Multilevel Opportunities to Address Lung Cancer Stigma across the Cancer Control Continuum. J Thorac Oncol. 2018;13(8):1062-75. Epub 20180523. doi: 10.1016/j.jtho.2018.05.014. PubMed PMID: 29800746; PMCID: PMC6417494.
  6. Banerjee SC, Haque N, Bylund CL, Shen MJ, Rigney M, Hamann HA, Parker PA, Ostroff JS. Responding empathically to patients: a communication skills training module to reduce lung cancer stigma. Transl Behav Med. 2021;11(2):613-8. doi: 10.1093/tbm/ibaa011. PubMed PMID: 32080736; PMCID: PMC7963287.


Originally published here in the Spring 2023  issue of  Outlook, the member newsletter of the Society of Behavioral Medicine, published here with permission from:

Society of Behavioral Medicine
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Phone: (414) 918-3156 • Fax: (414) 276-3349 • Email: [email protected] •