A qualitative review of cannabis stigmas at the twilight of prohibition

Abstract

Background

As of the writing of this review, 11 states have legalized cannabis for adult use while 33 have made it available medically. Relatedly, the number of Americans using cannabis has been increasing year by year, with an estimated 15.9% using cannabis within the past year (SAMHSA 2019). Numbers like these suggest cannabis is becoming more commonplace in American society, but have things advanced far enough to say that cannabis is normalized? This qualitative review of the social scientific literature on cannabis suggests claims of normalization may be premature. While access and use rates are increasing, anti-cannabis stigmas are still formidable forces in the USA.

The purpose of this review has been to synthesize the body of empirical literature on both medical and nonmedical cannabis use with attention to stigma, stereotypes, and other social consequences. While medical patients and recreational users have different motivations for using cannabis and perhaps diverging experiences, their identity is similarly devalued since they are associated with the same plant. Furthermore, a prominent theme in the social science literature on cannabis is that of blurred boundaries, a term referring to the unclear line between medicine and recreational intoxicant (Ryan and Sharts-Hopko 2017; Satterlund et al. 2015; Bostwick 2012; Reinarman et al. 2011; Chapkis and Webb 2008; Osborne and Fogel 2008; Page and Verhoef 2006; Ogborne et al. 2000; Grinspoon 1999). There is a significant overlap between medical and recreational applications of cannabis, and people who use cannabis for medical purposes also situationally use their medicine in a manner similar to recreational users. The opposite is also true where all use can be seen as medical since the individual receives some health-promoting benefit, even if it is just relaxation. As such, these two subsets of cannabis users are combined in the ensuing review.

The information presented here is primarily drawn from empirical studies on cannabis users in the USA, though studies from similar national contexts are cited as well (Canada and the UK, in particular). These are occasionally supplemented with studies concerning the stigmas faced by sexual minorities in order to better illuminate the nature of cannabis stigmas. Each are concealable (or invisible) stigmas since they may not be immediately observable to onlookers, and comparisons to sexual minorities are somewhat common in the literature on cannabis users (Newhart and Dolphin 2019; Lau et al. 2015). The comparison is useful in explicating stigmas related to concealable traits, but it is nevertheless imperfect because sexual identity is best conceptualized as an ascribed status, something largely fixed within the individual. On the other hand, drug use—or more aptly, sobriety—is best conceptualized as an achieved status since it is something that can be altered through individual endeavors.

This is also the first known attempt to document cannabis stigmas as they manifest on multiple analytical levels. Following brief explanations of the normalization hypothesis and the concept of stigma, this review differentiates and explicates structural (macro) stigmas, social (meso) stigmas, and personal (micro) stigmas. Finally, while a comprehensive discussion of ways to combat lingering social stigmas is beyond the scope of this review, it concludes by highlighting some of the ways to resist or eliminate stigmas as identified in the social scientific literature.

Normalization

The principle of normalization originally came from studies on disability (Wolfensberger and Tullman 1982) and has since been used as an interpretive tool for how cannabis is becoming an ordinary intoxicant in society (Sandberg 2012). The term is not used uniformly, though. Wolfensberger (2011) advocates that normalization should be understood as social role valorization for people who are at risk of social devaluation, where those with social stigmas are respected as filling valuable social roles. As applied to drugs, however, normalization is often taken to mean that a society’s attitudes and behaviors treat drug use as an unremarkable feature of everyday life (Pennay and Measham 2016; Parker 2005). While cannabis has become more commonplace in American society, this is only one of many components of the normalization process.

Largely starting in the 1990s, the normalization of cannabis has since become a prominent theme in sociological studies and is used to suggest that a society’s moral boundaries surrounding cannabis have been redrawn to accommodate non-abusive use (Duff et al. 2012; Sandberg 2012; Parker et al. 2002). The argument that “sensible” recreational drug use is normalized originated from longitudinal research on UK teenagers in the 1990s (Parker et al. 2002). Further developed by Parker (2005), normalization in the context of cannabis would take into consideration the following six dimensions: (i) the availability and accessibility of cannabis, (ii) cannabis trying rates and future intentions among nonusers to try cannabis, (iii) recent and regular cannabis use, (iv) the social accommodation of cannabis use where nonusers respect the right of others to use cannabis, (v) the cultural acceptance of cannabis where it is presented and understood as uncontroversial, and (vi) non-problematizing rhetoric and actions made by the government on cannabis (see also Pennay and Measham 2016; Duff et al. 2012).

Unfortunately, perhaps since some these dimensions are more easily quantified than others, claims that cannabis is normalized typically glance over the social and cultural dimensions. Indeed, critics have argued sweeping claims of normalization are oversimplified because social and cultural tolerance towards cannabis varies on a number of factors (Hathaway 2004). Since social contexts are largely ignored in statistical studies, normalization arguments need to do a better job of accounting for how different social groups perceive cannabis. For example, Erickson and Hathaway (2010) believe normalized cannabis use is a youth phenomenon. The concept of normalization originated from research on youth populations, and owing to how governments fund drug (ab)use studies, most empirical research on cannabis users focus on youth populations for the purposes of prevention (Garner 2016; Duff et al. 2012; Hammersley and Leon 2006). Yet perceptions about cannabis differ between generations so much so that age is one of the most powerful predictors of support for cannabis legalization (Elder and Greene 2019).

Another perspective in the normalization debate sees cannabis normalization as contextual since users navigate social settings of both normalized and stigmatized cannabis use (Lau et al. 2015). Others have acknowledged that the normalization process varies across social contexts (Hathaway et al. 2011), with Duff et al. stating: “Normalization ought to be understood as both broad social and cultural phenomena, as well as a disparate, contingent and uneven feature of local, micro-level, processes and contexts” (Duff et al. 2012:280). While no one denies that perceptions of cannabis vary between social settings and social groups, those who claim cannabis is normalized frequently generalize group-specific findings to the whole of society. More often than not, the groups on which such claims are based are those with social privileges (whites, males, and youths in particular) (e.g., Jarvinen and Demant 2011; Osborne and Fogel 2008; Parker et al. 2002).

It also might be wise to question the utility of applying the concept of normalization on a situational basis. Afterall, is not every deviant activity more or less normal depending on the social setting? Cannabis consumption is normal at a Cannabis Cup competition, just like public nudity is normal at a nude beach. This is why normalization is better understood as occurring on the societal and/or cultural levels. There has been some degree of cultural accommodation surrounding cannabis, but as this review will demonstrate, American society has yet to move beyond the stereotypes, stigmas, and structural penalties that have been endemic for so long.

Stigma

In the social sciences, research on disgraced identities stems from the work of sociologist Erving Goffman and his influential book, Stigma: Notes of the Management of Spoiled Identity (Goffman 1963). Loosely defined, stigma describes a part of the self that is socially devalued to where it becomes morally offensive. This aspect can be a physical abnormality, faults of an individual’s character, or membership in a distasteful group. Either way, the “undesired differentness” (5) negatively distinguishes the individual from normal individuals in a society (Goffman 1963). This negative evaluation goes beyond individual sentiments and is a form of shared cultural knowledge, often making the stigmatized targets of socially acceptable prejudice and discrimination. As other scholars have built on Goffman’s foundational work, five defining features of stigma have so far been identified (Herek 2004). These include the following: (i) the endurance of stigmatizing features within individuals, (ii) the socially constructed meanings of the stigmatizing feature, (iii) the negative evaluation of the stigmatizing feature by society, (iv) the tendency of the feature to become a master status, engulfing the entire identity of a person, and (v) the oppression of stigmatized groups through the restriction of power, resources, and social rights.

Contemporary conceptualizations of stigma are becoming more attentive to socio-cultural contexts and variations in experiences among the stigmatized (Livingston and Boyd 2010). For example, instead of cannabis use carrying a uniform social stigma, some scholars argue the stigma surrounding cannabis now only applies to irresponsible use (Lau et al. 2015; Duff et al. 2012; Hathaway et al. 2011; Jarvinen and Demant 2011). In other words, moderate recreational use may have become normalized while excessive and/or dependent use is still problematized as drug abuse. As such, a “normal marijuana user” is one who practices self-control, discretion, and moderation (Duff et al. 2012). Similar sentiments have been found among medical cannabis patients who routinely emphasize the need for responsible use, often balancing symptom management with self-imposed limits on consumption during the workday (Newhart and Dolphin 2019). Hathaway et al. say, “A sense of normalcy is preserved by avoiding attributions and behaviors seen as risky, and thereby the associated stigma” (Hathaway et al. 2011:456). Any residual stigma may function to discourage abuse of marijuana, as “participants routinely insisted that this stigma had more to do with the circumstances of [marijuana] consumption than with the act itself” (Duff et al. 2012:281). This argument has its merits, but it conceals stigmatizing forces which oppress responsible and abusive users alike.

Once again, normalization theory applied to cannabis would assume there is no longer a powerful stigma associated with being a known cannabis user (Sandberg 2012; Wolfensberger 2011; Parker et al. 2002; Goffman 1963). While abusive use in certainly stigmatized, other studies suggest the stigma associated with the plant is applied to all users, no matter the context. For example, one striking finding from Satterlund et al. (2015) was that many medical cannabis patients used the word “stigma” unprompted by the interviewer. Their use of this word was consistent with how it is used in the social sciences, indicating the participants had an accurate understanding of the nature of stigma. They knew their medicine was viewed negatively by society and that their status as a user would result in judgment from others, despite their use of cannabis being medically justified.

While the stigma surrounding cannabis appears to have diminished, there is little evidence that such stigma has entirely disappeared. Medicalization and legalization certainly help reduce cannabis stigmas, but these transformations in policy do not entirely shift social perceptions on their own. As will be demonstrated in this review, the lived experience of a post-prohibition society is not the same as a one where cannabis is normalized. Such policies remove structural sources of stigmas, but since stigmas vary in their source, negative attitudes towards cannabis stem from a combination of overlapping institutional, social, and individual forces (Hammer 2015). The different sources and manifestations of cannabis stigmas are explored here. Since cannabis stigmas are similar to the stigmas faced by sexual minorities in that each is physically concealable, the two groups are occasionally compared here because the literature base is more extensive with the latter. Moreover, as stigmas interact on multiple analytical levels, research on stigmas applied to sexual minorities has differentiated between structural, social, and micro stigmas. The following is an attempt to do the same.

Resistance and empowerment

The extensive evidence of cannabis stigmas troubles sweeping claims that cannabis is normalized. While sentiments towards cannabis have been improving in American society, it is doubtful that cannabis use is no longer a source of status loss. This is why resisting stigmas is important, as stigmatized people often face a vicious cycle of compounding disadvantages. Stigmas are associated with lower levels of hope, self-efficacy, self-esteem, social support, and quality of life (Livingston and Boyd 2010). Stigmatized people may respond with anger, self-imposed isolation, or attempts to conceal their identity, all of which are associated with negative mental health outcomes (Ahern et al. 2006). So how can stigmatizing forces be resisted or combated?

From a psychological standpoint, self-stigma can be reduced through one of two general strategies (Mittal et al. 2012). The first strategy is to alter stigmatizing beliefs and attitudes in an individual through practices such as cognitive restructuring and psychoeducation. The second strategy, which is gaining popularity among stigma experts, is one of mindful acceptance. This latter approach does not challenge stigmatizing forces or stereotypical thinking, but instead aims to make the individual more comfortable with their current self. Mindful acceptance can enhance a person’s overall self-esteem, empowerment, and help-seeking behavior (Mittal et al. 2012). Basically stated, others will judge a person for using cannabis, but since there is little that person can do to change the perceptions of others, it is best for that person to not waste their time worrying about it.

Yet the most effective stigma reduction strategy may be in changing societal beliefs and attitudes (Herek et al. 2009). If stigma is conceptualized as being a top-down model wherein individuals internalize negative cultural stereotypes, it makes sense to enact destigmatizing changes on the structural, cultural, and organizational levels. Changes in drug policy may help shift cultural frameworks surrounding cannabis by stopping institutional messages aimed at presenting users as morally deficient, criminal, or psychologically ill (Hathaway et al. 2011). Such structural changes can be accomplished through legal reform, but also through educating institutional leaders and publicly addressing the consequences of cannabis’ criminalization (Bottorf et al. 2013). This last element—tackling the legacy of prohibition—is particularly important as legalization by itself may not meaningfully reduce stigmas for those with less social privileges. A good example of this can be found in a statement by Anqunette Sarfoh, a former news anchor who quit her job to open a medical cannabis dispensary. Here she reflects on the challenges in recruiting diverse staff in the city of Detroit:

In our community, cannabis use has been stigmatized, because of how the legal impacts have affected our community… In [white] communities, kids can go in a cornfield and smoke a joint and go on about their lives. But in our communities, what happens when you’re caught, your future is gone. And so for the longest time, you just don’t even touch it and you grow up knowing that it could ruin your life (Anqunette Sarfoh quoted in Gray 2019).

Even after cannabis is legalized, the trauma resulting from prohibition will continue to exist as will entrenched anti-cannabis ideologies. Thankfully, many cannabis users already exhibit tertiary deviance (Bottorf et al. 2013), defined as deviants who fight to change social stigmas related to their identity. Primary deviance is characterized by denial, secondary deviance is categorized as acceptance, but tertiary deviance is characterized by advocacy and mobilization (Adler and Adler 2016/1994; Becker 1973/1963). Empowered individuals may become public representatives for their stigma (Lloyd 2013; Goffman 1963), a situation now evident with celebrities sharing their stories of using medical cannabis or cannabis for pleasure. Nonetheless, there seems to be a greater need for public representations which reflect the diversity within the cannabis community rather than the familiar white men in suits.

Similarly, Newhart and Dolphin (2019) propose three ways cannabis stigmas can be eroded. The first is the public identification of cannabis users so that their diversity becomes visible to others. A visible cannabis community would challenge flattening stoner stereotypes which assume all users have similar negative qualities. Indeed, cannabis users are a heterogeneous group with a significant degree of diversity (Loflin and Earleywine 2014; Osborne and Fogel 2008). Society may discover, for example, that high achievers like graduate students and college professors use cannabis regularly (Garner 2016). This public identification will also reveal how cannabis users can be found within everyone’s social network, which is the second strategy proposed by Newhart and Dolphin (2019). Non-users may learn that they have respected friends, family, and associates who use cannabis. This can be seen in the study by Bottorff et al. where one participant transformed her once-disapproving mother into a “full on cannabis granny” (Bottorf et al. 2013:7).

Finally, stereotypes can be challenged by identifying the source or perpetrator. Pointing out how the government, media, and others create and reinforce these misconceptions dispels the stereotype’s naturalness. In other words, these devaluations and characterizations are social constructions, not hard truths supported by objective evidence. In fact, participants in several studies thought much of the stigma surrounding cannabis use is a result of societal ignorance or deliberate misinformation (Satterlund et al. 2015; Hathaway et al. 2011). Nonetheless, while challenging deceptive sources of information about cannabis is a good practice, the general public’s perception of drug use is also shaped by their personal experiences and their surrounding environments. Spaces that facilitate contact between the public and the stigmatized can change negative attitudes, relying on the principle that with familiarity comes empathy (Lloyd 2013; Herek 2007). As such, creating regulated spaces for social use may not only be of service to individual cannabis users, but these spaces may also help normalize cannabis within larger society.

Conclusion

In his exploration of the deep history of cannabis throughout the world, John Charles Chasteen concludes it has been a substance associated with outsiders in every society. Until the latter part of the twentieth century, cannabis was “used by the poor, by the marginal, by the chronically ill, by the artistically and philosophically and spiritually inclined, by seekers after the meaning of life, and by social and religious nonconformists of various stripes” (Chasteen 2016:137). Stated otherwise, the deviant status of cannabis may be universal as groups associated with the plant are traditionally positioned apart from respectable society. The degree of this deviance varies over time and space, but considering this historical constant, scholars should be careful of claiming cannabis normalized unless the body of evidence thoroughly supports such a claim. As has been demonstrated in this qualitative review of cannabis stigmas, the deviant status of cannabis in American society still appears to hold true. Even today with cannabis, the “worst consequences, social and individual, seem to arise from how nonusers react to users” (Becker 1973/1963:200).

The debate surrounding cannabis normalization is ongoing and much work still needs to be done in the area. Though this review focused on cannabis users as a single class, it may be interesting to examine if stigmas differ between occasional and frequent users. Furthermore, most of the literature on cannabis normalization focuses on the macro, rather than micro, levels of analysis (Duff et al. 2012). There is little research on how social groups or individuals come to change their views on cannabis, though there is some evidence that institutional change requires activism and patience. Normalizing a stigma necessitates a significant cultural shift often occurring over many years or decades. As such, the intent here was not to rain on the parade of cannabis activists who have steadfastly progressed the status of the plant. Instead, the intention has been to show that once a stigma is established within a society, it is very difficult to change or remove. The still-marginalized status of sexual minorities once again demonstrates this phenomenon.

In sum, prevailing cannabis stigmas problematize linear narratives of normalization. No one doubts remarkable improvements have been made in recent times, but claims that cannabis is normalized at the societal level may be premature. Such claims may be symptomatic of unchecked social privileges or social distance from cannabis users. They may also be the product of valuing quantitative data over the nuanced accounts gained through qualitative investigations. Rates of legalization and use statistics do not capture the often-subtle struggles those in the cannabis community face in their everyday lives. As such, those investigating this topic should be careful not to overgeneralize arguments about normalization unless they can account for quantitative and qualitative changes among diverse groups and social settings. Significantly more attention should be placed on the dimensions of cultural and social accommodations in the normalization hypothesis. Furthermore, future research on cannabis stigmas should strive to incorporate and empower the most vulnerable in the community. Doing this will not only protect against making privileged claims to normalization, but it may also serve to identify meaningful strategies to further normalize the plant in society.

Acknowledgements

Author’s contributions

Dr. Reid is responsible for the research and writing of this manuscript. The author read and approved the final manuscript.

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Competing interests

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Footnotes

References