Validity and reliability of the internalized stigma of smoking inventory: An exploration of shame, isolation, and discrimination in smokers with mental health diagnoses

Tobacco use in the US has become de-normalized over the last fifty years.1 As tobacco use has declined, smoking has moved from once being viewed as normal to now an aberrant behavior. As a consequence, smokers have become increasingly concentrated in underprivileged and marginalized groups characterized by low-income, unemployment, lower education, and mental illness.2,3 While 18% of US adults smoke tobacco, the smoking prevalence among community-dwelling individuals with mental illness is 36%,4 and 60% among acutely hospitalized psychiatric patients.5 The health consequences are significant for individuals with serious mental illness who face a 25 year shortened survival on average.6 In addition to the health disparities experienced by smokers, psychosocial factors such as smoking stigma can cause additional strain on health, and may thwart positive behavior change. Smoking stigma can be defined as a social process by which exclusion, rejection, blame or devaluation occurs,7 in this case related to smoking or being identified as a smoker. Stigma can be categorized as: 1) internally-focused self-stigma resulting from the internalization of public stigma and characterized by statements about the individual's worth, e.g., “I am worth less because I smoke” 8; 2) perceived or felt stigma, which is an awareness of devaluation or stereotype in work, social, and everyday situations,7 and includes fear of being stigmatized, experiencing external blame, and social isolation; or 3) enacted stigma, which refers to acts of discrimination perpetrated on stigmatized individuals.9 In in-depth interviews and focus groups with 86 young adults in New Zealand, both smokers and non-smokers perceived the existence of smoking stigma and reported participating in discriminating and stigmatizing behavior towards smokers.10 Other qualitative work on smoking stigma experiences has discussed themes of: 1) smoker self-ostracization,11,12 resulting in the creation of “smoking islands” where smoking is accepted and condoned13; 2) non-smoker-imposed social isolation with projected negative and distancing “anti-social” and “other” labels given to smokers14; 3) perceptions of being a bad parent as a result of being a smoker (e.g., bad caregiver for mothers,11 bad protector and provider for fathers12); and 4) a “deep divide” perceived by smokers between those who smoke and those who do not.10 An interview study in Scotland found that some smokers even stigmatized other smokers by creating divisions based on perceived cleanliness: “I'm not a dirty smoker,” “I don't throw butts around”.11 Smokers have indicated that they manage the shame of smoking with cleanliness rituals including hand washing and teeth brushing.12 Three survey studies with over 800 adult smokers and ex-smokers from New York City make up the known quantitative research concerning smoking stigma. About half of the smokers and former smokers reported experiencing smoking stigma (assessed using five 4-point Likert scale items) focusing on devaluation (perception that others looked down on smokers) and differential treatment (discrimination); 17% of respondents reported direct discrimination (i.e., denial of apartment rentals, job opportunities, and health insurance) because of their smoking.15 Smoking stigma was found to originate from beliefs that smoking is a personal “choice” (and not an addiction) and fears associated with health risks of secondhand smoke.1 Additionally, patients who believed smokers are devalued compared to non-smokers were more likely to report keeping secrets from medical providers, suggesting that stigma may interfere with quality healthcare.16 Finally, these studies linked perceived smoking stigma to: social withdrawal; experiences of smoking-related discrimination; smoke-free environments (i.e., smoke-free workplaces and homes); and beliefs that “weak character,” “bad genes,” and stress cause smoking.1,15 Expanding beyond direct experiences with discrimination and devaluation to assess perceptions of social exclusion and self-judgment from the viewpoint of smokers, we aimed to further develop research on smoking stigma. Building from research of stigma formation with regard to mental illness stigma,17 we sought to create a brief, valid, and reproducible measure of perceived smoking stigma that would include discrimination and devaluation elements and self-stigma. In evaluating the construct validity of the measure, we considered modeled precursors, perceptions, and responses to smoking stigma, drawing from the Lung Cancer Stigma Model as a theoretical framework (Figure 1).18,19 Smoking stigma in the model is characterized by identification as a smoker, physical triggers (including smell and coughing) indicating smoking, and social context (precursors); experiences of discrimination, isolation or shame (perceived smoking stigma); and responses ranging from increased smoking to attempts to quit. Herein, we report on the factor structure, reliability, and construct validity of the resulting Internalized Stigma of Smoking Inventory (ISSI), and address the following model-derived research questions: (1) are concepts of discrimination, isolation, and shame reflected in the ISSI; (2) are elements of smoking stigma associated with readiness to quit smoking, as a modeled response; and (3) what proportion of the reported experience of smoking stigma is uniquely accounted for by smoking-related behavior, versus experiences of stigma in other domains, namely ethnicity and mental illness-based. Figure 1