Transcript
Announcer:
This is Project Oncology on ReachMD. On this episode, Dr. Lisa Carter-Bawa will discuss how tobacco-related stigma can impact lung cancer screening uptake. In addition to being the Director of the Cancer Prevention Precision Control Institute at the Hackensack Meridian Health Center for Discovery & Innovation, she’s also a Co-Leader of the Cancer Prevention and Control Program and the Deputy Associate Director of Community Outreach and Engagement for the Georgetown University Lombardi Comprehensive Cancer Center. Let’s hear from Dr. Carter-Bawa now.
Dr. Carter-Bawa:
What we know is that tobacco-related stigma doesn't just affect how a person feels; it fundamentally shapes whether they engage with lung cancer screening at all. People who smoke or who formerly smoked often carry this deep sense of self-blame. There's a pervasive cultural narrative that says, "You did this to yourself." And when someone internalizes that message, the screening visit can feel less like an opportunity for early detection and more like a moment of judgment, if that makes sense.
So what happens is that stigma becomes a barrier at multiple points along the screening pathway, and it can prevent people from even scheduling that initial visit because they anticipate being judged and being shamed. It can lead to underreporting of their smoking history, which compromises clinical accuracy. And it can cause people to disengage from follow-up care, even when abnormal findings require it, because there's this emotional weight of the experience, and that is sometimes too high.
In my own work, I've argued that we need to think about stigma not just as an interpersonal experience, but as a social determinant of health. I recently published a framework in the Milbank Quarterly that makes the case that tobacco-related stigma operates at the individual level, the interpersonal level, the institutional level, and at policy levels, and that if we only address it at the clinical encounter level, then we're missing this structural force that perpetuates it. And so when we take this broader view, we start to see that a patient's perception of lung cancer screening is shaped long before they walk into that clinic door. It's shaped by media portrayals, by public health messaging that relies on fear and blame, and by institutional practices, frankly, that may inadvertently reinforce that idea that people who smoke are kind of less deserving of compassionate care. The stigma attaches to the disease itself, not just to the behavior.
So think about what happens when someone says they have lung cancer. The very first question that they get from friends, from family, and sometimes, from a clinician is, "Did you smoke?" And that question is the stigma. It's asking the person to account for themselves before anyone offers them sympathy or empathy. And people who never smoke carry it too, and they end up defending themselves. The first thing they say is, "I never smoked a day in my life," which is a completely human response, but it reinforces the very hierarchy that hurts everyone. It says there's a deserving version of this disease and an undeserving one.
And then there's the other half of it, which is nihilism. Lung cancer still carries this cultural shorthand of a death sentence and that shows up in patients and in clinicians. If you believe nothing can be done, you don't screen, you don't refer, and you don't push for treatment. So stigma tells people they don't deserve care, and nihilism tells them it wouldn't help anyway.
So those two things together are why we're still under that 20% uptake rate in lung cancer screening itself.
Announcer:
That was Dr. Lisa Carter-Bawa discussing the impacts of tobacco-related stigma on engagement with lung cancer screening. To access this and other episodes in this series, visit Project Oncology on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!
