Risk perception and moralization among smokers in the USA and Denmark: a qualitative approach.

Because risk perception is one important precursor to behavior change (e.g., Weinstein, 2000), considerable research has focused on the extent to which smokers realistically perceive the risks they take (e.g., Romer & Jamieson, 2001). Smokers do acknowledge some risks; smokers for example typically think that their own risk of contracting smoking-related illnesses is greater than that of nonsmokers (e.g., McKenna, Warburton, & Winwood, 1993; Strecher, Kreuter, & Kobrin, 1995). However, smokers perceive these risks to be less serious than nonsmokers perceive them to be (e.g., Slovic, 2001; Weinstein, Marcus, & Moser, 2005). Smokers also tend to think they are personally less at risk than smokers in general (e.g., Lee, 1989) and think that their brand of tobacco is less dangerous and has less tar than the brands of other smokers (Segerstrom, McCarthy, Caskey, Gross, & Jarvik, 1993). Thus, smokers are not completely insensitive to the risks that they undertake by smoking. Still, smokers engage in a consistent pattern of risk minimization which leads them to conclude that although smoking is not exactly good for their health, it is also not that bad. Although we know much about the risk beliefs of smokers, we know little about how people come to believe that they are personally at risk and what role cultural messages play. One important cultural factor is moralization, which is the individual and cultural process by which preferences are converted into values (Rozin, 1997). Simply put, a behavior is moralized when it is considered a moral act and inherently bad as opposed to just a personal choice or preference. Moralization is important because values as opposed to preferences are more durable, more central to the self, and more internalized (Rozin, 1997). Values also invoke more intense emotional reactions, including disgust (Rozin, 1997). Furthermore, values are more likely to receive institutional and legal support and more likely to be transmitted from parents to children (Rozin, Markwith, & Stoess, 1997). Of note, once a behavior such as smoking has become moralized the behavior is viewed as a moral transgression and the smoker as morally reprehensible. The perceived violation of a moral code is similar to, yet distinct from, social norms (e.g., social denormalization of smokers) which refer to views of smoking more broadly as an abnormal and undesirable practice without referring to the moral nature of the behavior (e.g., Hammond, Fong, Zanna, Thrasher, & Borland, 2006). Many behaviors can move from a neutral state of individual choice to a state of moralized entity (see discussion of moralized behaviors across time and cultures in Brandt & Rozin, 1997) and cigarette smoking is one behavior which has become highly moralized in the U.S. in the last 30–40 years (Brandt, 1998; Rozin & Singh, 1999). In addition to stigma and moral disapproval, moralized behaviors often involve perceived harm to oneself (e.g., drug use is morally wrong in part because it is harms the user) as well as innocent victims. Causing harm to oneself might be seen as immoral but could be acceptable in an individualistic society. However, causing harm to others is typically viewed as immoral and gives license to override individual rights in the interest of preventing bystanders from becoming victims. The identification of innocent victims also heightens the interest of the State in controlling behaviors that were previously seen as outside its purview and “unleashes moral fervour for redress and justice” (Brandt, 1998, p. 172). Thus, perception of harm to others provides a basis for moralized action. Perceptions of harm to others might also increase as a given behavior becomes moralized. Societies that value autonomy and individualism, such as the U.S. and Denmark, will not easily thwart individual choices, even if those choices are health-related. Therefore, significant justification is typically required for prohibitions and limitations of smoking rights. One justification is that smoking harms not only smokers but also nonsmokers. So although individuals might express contempt or disgust for smoking and smokers, individuals as well as societal institutions are more comfortable relying on epidemiological data about health risks to nonsmokers to support smoking restrictions and stigmatization of smokers (see Katz, 1997, for a discussion of secular morality). Thus, perceptions of smoking danger (to the smoker and to others) support moralized action and moralized action in turn promotes further public discourse about the dangers of smoking (via health promotion campaigns, anti-smoking efforts in schools, public smoking prohibitions, funding for smoking research, etc.). One would expect that greater moralization is associated with greater perception of risk (to the smoker and non-smoker) in a given culture and conversely that less moralization is associated with greater skepticism and rejection of the risks of the moralized entity. The link between smoking moralization and risk perception has not previously been examined. To further explore the effects of culture, it is useful to compare cultures that differ in smoking attitudes. Historically, U.S. cultural values have emphasized independence, autonomy, and the right to take risks if one so pleases. Prior to the 1970s, cigarette smoking was considered an acceptable voluntary health risk (Brandt, 1998). This perspective changed fundamentally when the health risks of passive smoking were laid out in a series of Surgeon General’s reports in the 1980s and 1990s. Despite the relatively weak data supporting the dangers of secondhand smoke, these reports created an effective anti-cigarette movement based on the premise that no one has the right to impose health risks on others (Brandt, 1998). In Denmark, cigarette smoking has also historically been viewed as a private matter, but one that is best controlled by limiting active smoking (for example, via high tobacco taxes and restrictions on tobacco advertising) as opposed to limiting passive smoking (for example, via restrictions on public smoking) (see Albaek, 2004, for a review). Denmark has been slow to adopt smoking bans compared to other European countries (Joossens & Raw, 2006). In August 2007, a Danish national smoking law banned smoking in public settings such as bars, restaurants, schools, work settings, and other public places. However, smoking rooms are still allowed in these settings, and bars smaller than 40 m2 are exempt (Danish Cancer Society, 2009a). Smoking prevalence is somewhat greater in Denmark than in the U.S.; in 2008 28% of adult Danes (Danish Cancer Society, 2009b) and 21% of adult Americans smoked (CDC, 2009). The difference in attitudes toward smoking in the U.S. and Denmark was shown in a survey study of young adults (Helweg-Larsen & Nielsen, 2009). In contrast to U.S. smokers, Danish smokers did not perceive that their personal lung cancer risk was increased the more cigarettes they smoked. Furthermore, Danes believed to a greater extent than Americans that smoking is a private matter (an attitude contradictory to a moralized view of smoking), that doctors exaggerate the dangers of smoking, and that smoking does not make others uncomfortable. In sum, the cross-cultural differences showed that Danish smokers, compared to American smokers, were more likely to minimize their personal risks of smoking and held less moralized attitudes toward smoking. These results described data collected over 10 years ago (prior to the proliferation of smoking restrictions) and concerned only young adults. Furthermore, although a survey study can capture many useful aspects of people’s attitudes, a quantitative interview study affords people the opportunity to fully describe attitudes and how they conceptualize and make sense of their smoking behavior. In this qualitative interview study we examined Danish and American smokers’ descriptions of (a) perceived risk of smoking (risk to self and others) and risk minimization, (b) moralization and reactions to being the targets of moralization, and (c) descriptions of risk-reducing behaviors, including limiting smoking around certain people or situations. We were interested in how participants experienced and discussed these elements and how participants found them to be related.