The important findings in this study are that regardless of whether or not a person with lung cancer has ever smoked, LCS has a strong positive relationship with depression and a strong inverse relationship with QOL. After controlling for gender, age, smoking status, and depression, LCS made a small but significant and unique contribution to the explanation of the variance in the QOL in a sample of lung cancer patients. This study supports the premise that perceived stigma among lung cancer patients, whether they smoked or not, can lead to negative outcomes including: increased levels of depression and diminished QOL.
There are several limitations to this study, the convenient online sample was a national sample that allowed us to reach a hard to reach population, with 38 states represented. However, this sample did not reflect the general lung cancer population. This sample was, younger, more Caucasian, more educated, and from a higher SES than the usual population of lung cancer patients. Because of the nature of online data, clinical information about the sample (i.e., diagnosis, stage of disease, treatment) was limited.
This study supports the previous qualitative work of Chapple and colleagues (Chapple et al., 2004
), whether they smoked or not, lung cancer patients report stigmatization from friends and clinicians, because the disease is strongly associated with smoking. Stigma, in part, stems from the fact that smokers have become a marginalized part of society (Stuber et al., 2008
). The denormalization of smoking has been a very effective tobacco control strategy. However, an untoward consequence of this approach is the stigmatization of smokers (Stuber et al., 2008
) and the tendency to blame the victim. The association of smoking with lung cancer has negative consequences for lung cancer patients. Because smoking is a proven cause of lung cancer, whether patients are smokers or never smokers, smoking is perceived to be a controllable factor and a behavior associated with lung cancer stigma (Weiner et al., 1988
). Several factors that contribute to the marginalization of smokers include: perceptions of smoking as a choice not an addiction; discrimination perpetrated against smokers through no smoking policies, and perceptions that smokers are less educated (Stuber et al., 2008
). Another factor that contributes to lung cancer stigma is the initial, very public battle by scientists and public health advocates versus the tobacco industry that smoking is bad for your health. Lung cancer was the standard bearer of that argument and the first disease to be directly linked with smoking cigarettes. Lung cancer has shared the public lime light with smoking for several decades. Recently, with the development of the lung cancer stigma scale, the empirical evidence is building, that whether or not lung cancer patients were ever smokers, they experience significant levels of perceived stigma. Because stigma has a strong significant correlation with increased depression and diminished quality of life, education about coping strategies to deal with stigma need to be incorporated into the care of lung cancer patients.
The mean CES-D score for this sample was 18.97 (54.9% of the total sample); using the >16 cutoff score, over half of this sample was depressed. Previous studies have shown that prevalence of depression among lung cancer patients has varied from 23% to 44% 3, (Carlsen et al., 2005
). The depression levels in this sample may be due to the online population. The possibility exists that this sample sought out an online support group because of depression. However, as a result of a lung cancer diagnosis, patients often experience increased psychological distress (Bottorff et al., 2009
; Henoch et al., 2007
; McBride et al., 2003
; Sarna et al., Jan 2005
). Because lung cancer patients experience more psychological distress than other cancer patients, stigma intervention and mood management needs to be an essential aspect of treatment. Lung cancer patients need to be evaluated and treated for stigma and mood disorders throughout their treatment course.
Higher QOL scores are associated with increased survival in lung cancer patients (Ruckdeschel and Piantadosi, 1994
; Ganz, 1994
; Buccheri et al., 1995
) A pre-diagnosis rating of QOL has been found to be the most significant predictor of the length of survival even after adjusting for known prognostic factors (Montazeri et al., 2001
) Lung cancer survivors do not experience the same length or quality of life as other cancer survivors (Sugimura & Yang, Apr, 2006
) In this study, after controlling for age, gender, and smoking status, LCS explained 2.1% (p
< 0.001) of the variance over and above the 22.5% (p
< 0.001) explained by depression. A significant consequence of LCS is a disruption in QOL (Van Brakel, 2006
). Therefore, prevention and or treatment of LCS could significantly impact on the quality of life for lung cancer patients.
The next stages of research should include: further examination of the multiple dimensions of lung cancer stigma in a larger, more diverse and representative sample; investigation of the character and magnitude of stigma and the relationships with symptom burden and QOL over time; and investigations of the impact of the stigmatization of lung cancer on the family members of patients with lung cancer. There is an urgent need to develop effective interventions to prevent and decrease LCS because it affects both patients and families and can contribute to strained relationships at a time when connectedness is needed. Effective stigma interventions could help both patients and family members manage and integrate the cancer illness experience into their everyday life.