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The Downside of Tobacco Control? Smoking and Self-Stigma: A systematic review Rebecca J. Evans-Polcea1, Joao M. Castaldelli-Maiab,c, Georg Schomerusd,e,1, Sara E. Evans-Lackof,1 1 authors contributed equally to the work a The Methodology Center and Prevention Research Center, Pennsylvania State University, University Park, PA, USA b Department of Psychiatry, Medical School, University of Sao Paulo, São Paulo, SP, Brazil c Department of Neuroscience, Medical School, Fundação do ABC, Santo André, SP, Brazil d e f Department of Psychiatry and Psychotherapy, University of Greifswald, Greifswald, Germany Helios Hanseklinikum Stralsund, Stralsund, Germany Department of Health Service and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK. Financial support This research was funded by grants from the National Institute on Drug Abuse (NIDA) - P50DA010075 and T32DA017629. SEL has a Starting Grant from the European Research Council. Conflict of interest SEL and GS have received consulting fees from Lundbeck unrelated to the current study. 1 Corresponding author: 204 E. Calder Way, Suite 305 State College, PA 16801 phone: 814-867-4511 revanspolce@psu.edu 1 Abstract Objective: Little is known about the consequences of tobacco smoking stigma on smokers and how smokers may internalize smoking-related stigma. This review summarizes existing literature on tobacco smoking self-stigma, investigating to what extent smokers are aware of negative stereotypes, agree with them and apply them to themselves. Methods: We carried out a systematic search of Pubmed/Web of Science/PsycInfo databases for articles related to smoking self-stigma through June 2013. Reference lists and citations of included studies were also checked and experts were contacted. After screening articles for inclusion/exclusion criteria we performed a quality assessment and summarized findings according to the stages of self-stigma as conceptualized in Corrigan’s progressive model of self-stigma (aware, agree, apply and harm). Initial searches yielded 570 articles. Results: Thirty of these articles (18 qualitative and 12 quantitative studies) met criteria for our review. Awareness of smoking stigma was virtually universal across studies. Coping strategies for smoking stigma and the degree to which individuals who smoke internalized this stigma varied both within and across studies. There was considerable variation in positive, negative, and non-significant consequences associated with smoking self-stigma. Limited evidence was found for subgroup differences in smokingrelated stigma. Conclusion: While there is some evidence that smoking self-stigma leads to reductions in smoking, this review also identified significant negative consequences of smoking self-stigma. Future research should assess the factors related to differences in how individuals respond to smoking stigma. Public health strategies which limit the stigmatization of smokers may be warranted. Keywords: smoking; tobacco use; self-stigma; stigma 2 INTRODUCTION Tobacco smoking is, in many countries, subject to restrictive public health efforts, aimed at discouraging smoking and making it an unacceptable behavior. Many public health institutions including the World Health Organization(2012) and the Centers for Disease Control(2014) advocate the denormalization of tobacco use and changing social norms around tobacco use to combat the negative health effects of tobacco. Approaches include smoke free air laws (Tynan, Babb, MacNeil, & Griffin, 2011), media campaigns (Wakefield, Loken, & Hornik, 2010), and pictorial health warnings on tobacco products (Cameron, Pepper, & Brewer, 2015; Hammond, 2011; Monarrez-Espino, Liu, Greiner, Bremberg, & Galanti, 2014). In addition, some organizations have instituted anti-smoking policies such as prohibiting the hiring of smokers (Asch, Muller, & Volpp, 2013) or requiring higher health insurance premiums for smokers (Madison, Schmidt, & Volpp, 2013). Alongside changes in social attitudes, these policies could contribute to the stigmatization of smokers (Bayer, 2008; Bell, McCullough, Salmon, & Bell, 2010a). However, social control strategies, which are employed in an effort to reduce the prevalence and incidence of smoking and reduce exposure of non-smokers to second-hand (Baxi et al., 2014) and thirdhand smoking (Ferrante et al., 2013), may actually further marginalize ‘residual smokers’ who may be more