Shame Is a Powerful Tool for Behavior Change, but at What Cost?

"Successful" smoking stigmatization strategies shouldn't be repeated for opioids.

Reviewed by Gary Drevitch

Key points

• Shame can be a powerful tool for health behavior change.
• While stigmatizing people potentially offering an easy fix, it harbors dangers as well.
• While a public stigma campaign worked for smoking, it should not be used for opioids.

The other day I received this email: “I hope you don't mind a 'cold email,' but this [post] in Psychology Today came across my inbox yesterday, and I thought of you. In it, [the author] argues for stigmatizing opioids (echoing back to anti-smoking campaigns…). .... I'm worried about the impact of this [post].”

As an anthropologist, I have written much about how this deployment of shame and other forms of stigma in public health—whether purposefully or incidentally—is almost always unexpectedly harmful and so easily becomes a driver of health inequities. It seems timely to revisit the fundamental concerns.

There is no doubt that stigma—demonizing people based on their behaviors or other arbitrary traits—can be deployed as a powerful behavior change tool in public health. Smoking is the stellar example, with stigma underpinning one of the most successful public health campaigns of the last century. Once cancer and other terrible health consequences of tobacco use became medically evident, public health faced the problem that behaviors rooted in physical addiction are very difficult to shift. Public health experts took a powerful stance: Don’t just make it harder to smoke; make it harder to be a smoker. Alongside taxes and advertising bans, campaigns were rolled out that were designed to make smoking socially undesirable. Given the intensity of efforts to label smokers as disgusting, dangerous, and weak, many smokers found the means to quit despite the physical difficulty of addiction. By the end of the start of the new millennium, public health experts declared the stigma-based campaign against tobacco a roaring success.

So, attaching stigma to an unwanted behavior—even an addictive one—can work very well for public health behavior change. Hence it can seem a compelling argument that this same vilification process could be applied to other public health issues, including opioid over-use and addiction. But social scientists have shown there are multiple unanticipated and harmful consequences that need to be considered very carefully. Tracking what has happened to smokers and smoke-related disease in recent decades provides some insights.

For one thing, many people still smoke. Those with more money, contacts, and education had more practical means to help them quit. So, smokers became increasingly clustered in lower-income communities, often the very same places now aggressively targeted by tobacco companies to generate sales. In lower-income communities in the U.S., for example, tobacco billboards are more common and larger, more stores sell tobacco, more point-of-sale promotions tout discounts on price, and there is generally greater social pressure to smoke. These are exactly the type of consequences of “successful” public health interventions that ultimately can improve health but worsen health disparities.

Moreover, the success of the war against tobacco users has now made a diagnosis of lung cancer utterly devastating. Many people—including never-smokers—avoid medical care and hide their condition from others. There is less investment in lung cancer research, especially when compared with more "morally worthy" diseases, like breast cancer.

Further, consequences from experiencing stigma like low self-esteem and social and economic marginalization are destructive to mental health. So it may be that trying to solve one problem (smoking) creates another (depression).

Opioid use is already stigmatized, which makes concerns about doubling down on this to force behavior change perhaps easy but also even more concerning. Opioid users are already labeled as “drug addicts,” creating substantial barriers to both those seeking care and to investment in medical research. The stigma allows clinicians or pharmacists to reduce or deny care. A recent article in the journal Social Science and Medicine collated the perspectives of those posting and commenting on a Reddit opioid subforum. These posters described the many ways that the pharmaceutical industry, insurance companies, and healthcare systems—not just individual players within them—stigmatize people who use opioids and the many ways those individuals are harmed. And they are acutely aware that many of these same powerful players created the bases for the stigma, being those that developed, marketed, sold, and prescribed opioids in the first place.

Thus any argument that powerful health-related institutions should be trusted to deploy stigma fails to recognize that stigmatizing is never a neutral process, and efforts can easily be derailed, co-opted, and otherwise deployed to the benefit of those with more power against those with less. This is why social scientists often talk not just of stigma, but of stigma power.

New opportunities for stigma to create health harms and inequalities are constantly emerging. Like the arguments about further stigmatizing opioid use, they are typically introduced by those whose intentions are fundamentally good. But these proposals alone can be enough to do significant damage to those who encounter them.

For example, our team has been researching how people using Ozempic and other new-generation weight-loss drugs are experiencing stigma around the decision to lose weight using pharmaceuticals. Many feel judged, as if they are “cheating” by using the drugs and should instead be furiously jogging, fasting, or using other means defined as “the right way” to lose excess weight. Much of this judgment comes from the people they interact with most in their lives, such as family or friends. But people who work in health care can also come across as judgmental. A snide remark from a pharmacist when you pick up a prescription, or a medical insurance carrier querying if you “really are doing enough” to "deserve" to be on the drug, can be painful.

Hence the argument we have made before: It’s better to just avoid using stigma as a public health tool and focus on devising other solutions.