66 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2011 vol. 35 no. 1© 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia

Framing responsibility: coverage of lung cancer

among smokers and non-smokers in

Australian television news

Abstract

Objective: To analyse news portrayals

of lung cancer and associated inferences

about responsibility in Australian

television news.

Methods: Analysis of television news

reports, broadcast on Sydney’s five

free-to-air television channels between

2 May 2005 and 31 August 2009, for all

statements pertaining to lung cancer.

Results: Of 2,042 reports mentioning any

cancer, 45 made reference to lung cancer,

and 28 (62%) referred to diagnoses of lung

cancer in non-smokers. Of 157 statements

in these reports, 107 (68%) noted that the

person featured was a non-smoker. Non-

smokers were portrayed sympathetically

and as tragic victims, implying they were

not responsible for their condition, the sub-

text being that smokers are responsible

for theirs.

Conclusions: Television news portrays

non-smokers with lung cancer with

considerable sympathy. Conversely,

smokers are implicitly and occasionally

explicitly depicted as responsible for

their disease.

Implications: The marginalisation of

tobacco caused lung cancer in news,

together with sympathetic reporting of lung

cancer in non-smokers may contribute

to stigma surrounding smoking caused

disease that may promote delay in

seeking treatment, and de-emphasise the

role of the tobacco industry’s decades-

long smoker reassurance program in

promoting smoking.

Key words: lung cancer, stigmatisation,

responsibility, media.

Aust NZ J Public Health. 2010; 66-70

doi: 10.1111/j.1753-6405.2010.00614.x

Ross MacKenzie, Simon Chapman, Simon HoldingSchool of Public Health, University of Sydney, New South Wales

Lung cancer is the leading cause of

cancer death both in Australia and

globally, accounting for an estimated

1.35 million annual deaths,1 yet it has been

recently described as an “unfashionable”2

cancer. In Australia, lung cancer ranks

fifth among all cancers in news coverage,

well behind breast, prostate, skin and brain

cancers3 and well below that which would be

predicted if news coverage paralleled cancer

death rates and person years of life lost.

This neglect may reflect the association of

lung cancer and smoking, which accounts

for approximately 80% of diagnoses.1 For

decades, the tobacco industry has argued,4-6

and many in the community have agreed that

smoking is an entirely individual choice,

owing little or nothing to industry marketing

and cultural factors reinforced and initiated

by the tobacco industry. The prevalence of

this view has contributed to perceptions that

lung cancer is a self-inflicted disease “tainted

by smoking”7 or a moral punishment.8 Such

attitudes can stigmatise smokers9-12 and those

diagnosed13-15 and diminish public sympathy

for those with the disease.16-17

Lung cancer ranks high as a cancer

characterised by delayed diagnosis.18

Individuals contracting a disease for which

they are held responsible may experience

embarrassment, delay seeking health care,

and be less likely to become involved in

advocacy or support groups aimed at fostering

greater support for and understanding of

their condition.19 Such reactions have been

observed among lung cancer patients who

have reported feeling especially stigmatised

Submitted: November 2009 Revision requested: February 2010 Accepted: April 2010Correspondence to: Prof Simon Chapman, School of Public Health, University of Sydney 2006, Australia. Fax: (02) 9036 9019; e-mail: sc@med.usyd.edu.au

“because the disease is so strongly associated

with smoking”,13 and having concealed

their illness, feeling “unworthy” of medical

treatment20 and delayed seeking treatment.

This situation may be compounded by the

dearth of support groups similar to those that

exist for many other cancers. This anomaly

may reflect poor lung cancer survival times,

but may also be because of the stigmatised

nature of the disease.7,21-22

Media reports have also occurred about

professional debates over whether smokers

should be accorded lower priority in surgical

waiting lists23-24 because of expressed

concerns about poorer prognosis and

arguments that their decisions to smoke

contribute to their condition. These debates

have not occurred with any prominence about

other conditions with lifestyle components

like obesity or alcohol-related trauma. Public

debate about whether sick smokers deserve

treatment would hardly make such patients

feel their problems attracted much sympathy.

Importantly, lung cancer also occurs in

those who have stopped smoking, sometimes

decades before the onset of symptoms,13

and in others who have never smoked,

having contracted it via exposure to second-

hand smoke (SHS) or because of genetic,

occupational or idiopathic factors. Never-

smokers may account for up to 15% of lung

cancers in men and 53% in women globally

(approximately 25% of all diagnoses overall)

constituting a sub-category that would

rank as the seventh leading cause of cancer

death.25 The dominant framing26 of smoking

as a volitional, self-destructive activity also

Smoking Prevention Article

2011 vol. 35 no. 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 67© 2011 The Authors. ANZJPH © 2010 Public Health Association of Australia

obscures related considerations including reduction of agency

caused by addiction, the near universal experience of regret among

smokers,27 millions of annual unsuccessful quit attempts28 and the

historic role of the tobacco industry in reassuring smokers about

health risks.29-30

The news media is the leading source of public information on

health issues,31 and a key influence on health policy formulation,32

but its coverage can reinforce and distort perceptions of key

issues33 and contribute to stigmatisation of health problems.34

Media coverage of cancer can disseminate important primary

and secondary prevention messages,35 but also create a sense of

inevitability of contracting the disease,36 and accentuate individual

lifestyle risks over potential social and environmental causes.37

Limited literature exists on media coverage of stigma and

smoking-related illness, although analyses of two smoking-related

compensation claims in Australia offer some insight. A 2003

study of print media coverage of a high profile lawsuit brought by

a terminally ill smoker against a leading cigarette manufacturer

found that 35% of reports contained statements holding the plaintiff

responsible for her predicament.16 In contrast, reportage of a case

involving a non-smoking woman who contracted laryngeal cancer

via second hand smoke (SHS) exposure at her workplace focused

on the need to protect individuals from such conditions and the

injustice involved.38

Previous research on cancer coverage on Australian television,

by far the country’s most popular mass communication medium,39

demonstrates that lung cancer is markedly under-reported on

television news relative to other forms of the disease in terms of

incidence and mortality.3 The aim of our analysis in this paper

is to explore whether existing coverage is consonant with, and

therefore contributory to, prevalent attitudes that hold smokers

responsible for their illness.

MethodsAll news, current affairs and infotainment items (entertainment

programs focused on information such as The Biggest Loser)

broadcast on five Sydney free-to-air television channels since

May 2005 have been electronically recorded and classified40 as

part of the Australian Health News Research Collaboration41

project, which monitors all television coverage of health issues

broadcast from Sydney’s five free-to-air channels. Data capture,

classification, coding and inter-coder reliability testing protocols

for this database are described in detail in a methods paper.42

Author SH digitised and coded 2,042 reports on any aspect of

cancer broadcast between 2 May 2005 and 31 August 2009 (see

http://tobacco.health.usyd.edu.au/share/TV.xls). Each report was

coded for specific cancer mentioned, with 45 explicitly mentioning

lung cancer. Author RM validated all these (100% concordance)

and categorised all (n=157) direct or indirect (“Dr X said ...”)

statements made by, or attributed to, news actors (patients, family

members, clinicians) or media personnel referring to any aspect

of lung cancer into seven broad content headings based on the

predominant focus of the news item in which they appeared

(see Box 1). Any explicit statements about the smoking status of

individuals with lung cancer were also noted (Table 1).

Results Of 20,305 reports on any aspect of health or medicine broadcast

on Australian television news during the study period, 2,042 (10%)

mentioned any form of cancer, and 45 (2% of all cancer-related

items) referred to lung cancer, the leading cause of cancer death.

Analysis of these 45 reports yielded 157 relevant statements,

almost two-thirds (n=107, 68%) of which referred directly to the

Box 1: Categories of statementsIncidence: references to the number of new cases of lung cancer, and any demographic characteristics of these cases.

Celebrity cases: any famous or well-known person, including family members of such persons.

Treatment: any statement about treatment modalities, success rates, access or cost.

Prevention: causes and risk factors for lung cancer, including genetic factors.

Profile of lung cancer: any mention of the experience of having lung cancer, or efforts to give it (and research into it) a higher public profile.

Diagnosis: statements about diagnosing or screening for lung cancer.

Regulation and control: statements about controlling smoking which explicitly referred to lung cancer.

Table 1: Focus of statements in 45 television reports mentioning lung cancer.

1. Categories and main examples found 2. Statement 3. Number of statements 4. Proportion of frequency specifying smoking statements in column 3 status of subjects pecifying subject was a non-smoker

Incidence: primarily non-smoking women 42 (27%) 36 (86%) 31 (86%)

Celebrity cases: Dana Reeves’ diagnosis and death 33 (21 %) 24 (73%) 24 (100%)

Treatment: poor prognosis; government funding 33 (21 %) 9 (27%) 0 (0%)

Prevention: risks /causes including genetic disposition to smoke 18 (11 %) 16 (89%) 3 (19%)

Profile of lung cancer: stigma; support; fund raising 12 (8%) 9 (75%) 9 (100%)

Diagnosis: new methods; current situation 12 (8 %) 6 (50%) 0 (0%)

Regulation and control: reports on tobacco control policy 7 (4 %) 7 (100 %) 2 (28%) referring specifically to lung cancerTotal 157 (100%) 107 (68%) 68 (63%)

Smoking Prevention Coverage of lung cancer in Australian television news

68 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2011 vol. 35 no. 1© 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia

smoking status of identified individuals with lung cancer (column

3, Table 1). Of these, 68 (63%) noted that the person with lung

cancer was not a smoker.

Incidence Statements on incidence (n=42) represented more than one-

quarter (27%) of the 157 statements made on lung cancer, and

were dominated (n=27, 64%) by news that lung cancer was about

to become the leading cause of cancer death among Australian

women. Of these 27 statements, 22 (81%) referred specifically to

lung cancer among non-smokers, described in one report as “tragic

victims of the fact that they have a disease that is associated with

smoking”.43 A 30-year-old woman interviewee was introduced as

a non-smoker by a breakfast news host who observed, “you can

imagine it came as a complete shock when she was diagnosed

with lung cancer”,44 while the description of another non-smoking

woman with the disease noted that “although she never smoked,

the vast majority of women with lung cancer have.”45

A further five statements referred to a former smoker who

had contracted lung cancer. Three others referred to lung cancer

incidence among non-smokers and the remainder focused on

related statistical reports.

Celebrity casesAll but one of the 33 statements in this category occurred in

reports of Dana Reeves’ August 2005 diagnosis of lung cancer

and subsequent death. Three-quarters (n=24) emphasised that

she was a non-smoker: “we had that very sad news last week of

Dana Reeves, Christopher Reeves’ wife, diagnosed with lung

cancer but she’s never smoked.”46 Only three statements referred

to SHS exposure during her singing career as the probable cause

of her illness.

Treatment Nearly two-thirds of statements related to treatment, n=21

(63%), and described the poor prognosis of lung cancer due to

frequent late diagnoses and the aggressive nature of the disease.

Six statements relating to government subsidisation of the

chemotherapy drug Alimta for smokers with lung cancer were

contained in reports that explicitly contrasted their situation with

that facing people diagnosed with the asbestos-related condition

mesothelioma, described as a “glaring inequity”.47 Similarly, a

2007 report observed that “many [mesothelioma] patients miss

out on subsidised treatment, while others who have the lung

disease as a result of smoking receive the subsidised treatment

for free”.48 The remaining statements in this category referred to

possible new treatments.

Prevention, risk and causes Risks and causes were the subject of 18 statements. Nine focused

on smoking, five on research into genetic disposition to smoking

and associated difficulties in quitting, one reflected on possible

non-tobacco related causes and three statements on prevention

referred to government policy initiatives.

Profile of lung cancer These 12 statements dealt with the impact of lung cancer’s stigma

on treatment, support and fundraising, nine (75%) of which (75%)

dealt specifically with non-smokers. One recently diagnosed, non-

smoking women described it as the “most stigmatised, ignored,

underfunded cancer of all”,49 while another expressed frustration,

“[w]hen you discover you have it, there is a shocking stigma, there

isn’t a lot of support out there unfortunately.”50 One health agency

official stated that the situation could result in delays in seeking

treatment, information and support, and lead patients to “feel they

have brought it on themselves”.50

Diagnosis Just over half in this category of statements (n=7) reported

on research into new diagnostic methods. The remainder

referred to many diagnoses being made when the cancer is at an

advanced stage.

Regulation and controlAll seven statements in this category were included in reports

on proposals to ban smoking in cars.

Discussion Smoking is a leading health news focus in Australia,51 ranking

21 out of 237 content areas as the most frequently reported health

issue on television.42 Lung cancer, however, is curiously under-

reported despite its status as the leading cause of cancer death, and

as the most widely recognised and resonant health consequence

of smoking.52 It seems plausible that previous journalistic interest

in tobacco-related disease may have waned, and that the subject’s

newsworthiness today lies more in unusual, ‘man bites dog’,

news angles.53 While 77% of lung cancer deaths in Australia

occur in smokers and former smokers,54 television news focuses

predominantly on non-smokers with the disease.

This emphasis on the plight of non-smokers with lung cancer

may imply an element of victim-blaming55 directed at smokers with

the disease. News reports highlighting apparent unequal access

to subsidised treatment for smokers with lung cancer compared

to people with mesothelioma carry a clear sub-text of differing

responsibility. Framing smokers with lung cancer as blameworthy

also distracts from the tobacco industry’s decades-long history

of smoker reassurance29 that has disingenuously disseminated

‘information’ that lung cancer was caused by air pollution;56 that

leading scientists disagreed that smoking was harmful;57 and that

nicotine was not addictive.58 The legacy of the industry’s campaign

is seemingly not restricted to past generations of smokers. As

recently as 2003, 45.8% of Australian smokers believed that

“smoking is no more risky than lots of things that people do”;

40.6% that “everything causes cancer these days”; and 22.9% that

“the medical evidence that smoking is harmful is exaggerated”.59

Smokers plainly retain considerable agency, as attested by

the consistency of data on large numbers of smokers quitting

unaided, often without much difficulty.60 But many smokers do

MacKenzie et al. Article

2011 vol. 35 no. 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 69© 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia

Smoking Prevention Coverage of lung cancer in Australian television news

have considerable difficulty stopping and experience repeated

relapse. As many in the community reason that today’s smokers

are inundated with information on its risks and are therefore

making a “rational choice” to smoke,61,62 those who continue to

smoke as it becomes even less prevalent in response to policies

and high profile campaigns will increasingly be portrayed as

‘having only themselves to blame’. It is perhaps inevitable that

those smokers who contract lung cancer will experience ever-

diminishing public sympathy. Ironically, as smoking becomes an

increasingly disparaged behaviour,63 increasing regulation and

initiatives designed to warn the public about its attendant risks

may further contribute to this challenge. Findings that graphic ‘quit

smoking’ television campaigns, while effective,64 have themselves

contributed to the stigma of lung cancer for their portrayal of

an inevitable “dreadful death”13 may, for instance, inadvertently

add to the stigmatisation of smokers, many of whom may also

experience social disapproval due to poverty, low social economic

status and race.65

A further consequence is that negative community attitudes

towards those seeking justice over misleading and deceptive

tobacco industry conduct16 may dissuade potential litigants from

pursuing legal action and influence juries should cases go to trial.

Efforts by the public health community to emphasise that today’s

lung cancer patients acquired their nicotine addiction in an era of

widespread tobacco industry malfeasance and government inaction

may go some way to lessening the stigma of smoking-related lung

cancer and making ‘the cancer journey’ for such patients less

stressful and alienated.

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