The what is and why bother with a critical public health

It is research that doesn’t intend to just understand a phenomenon by uncovering “facts” that we gather through a specific “mechanical process”,¹³ but instead it is explicitly focused on challenging the status quo — challenging what “we” believe to be true in public health, and attempting to understand phenomena within the oppressive structures of our society in which those phenomena exist and/or emerge.^{9, 12}

The first is that the publics — as in the publics in public health, their experiences of the world, particularly as they are structured in an inequitable society — shape the ways in which they engage in their everyday lives, the choices that are available and that they make, the behaviors they engage in or don’t engage in.

This isn’t rocket science, but what is often neglected is that that very knowledge may often lie in direct opposition to the working knowledge that surrounds our work in public health, and how public health is defined within our fields.

By doggedly pursuing strategies that are defined by our existing knowledge, by what the orthodoxy thinks is important for protecting and promoting people’s health, we may fail some groups of people.

Since 1988, for example, smoking prevalence for Californian adults has declined from 23.7% to 11.7% in 2013, which is a 51% reduction. But, these same reductions have not occurred within sexual and gender minority groups where prevalence of smoking remains high. Estimates from the 2013 California Adult Tobacco Survey suggest that sexual minority adults smoke more than twice as much — 27.4% compared to 12.9%.

And though similar data on smoking prevalence for transgender and gender nonconforming adults were not collected, older California and recent national estimates suggest that trans adults are twice as likely to use cigarettes compared with cisgender adults (that is adults whose gender identity corresponds to their sex assigned at birth).^{7, 8} So the evidence suggests that these groups of adults are much more likely to smoke compared to cisgender, heterosexual adults. Because of this inequity, sexual and gender minorities have come to be identified as a priority population in tobacco control.

So what’s going on here? One thing we were particularly interested in investigating was the role of stigma.

Tobacco denormalization is interesting, in comparison to the prevention and treatment of other substances, in that it explicitly endorses stigma rather than working to mitigate the stigma of the substance and the substance user. Smoking has come a long way from the glamorous and sophisticated image that it once conveyed.

Anti-smoking sentiment is now quite pervasive, raising debates among some scholars about the ethics of tobacco denormalization’s use of stigma as an explicit public health strategy. The stigmatization of the smoker is illustrated in studies of anti-smoking sentiment and the negative stereotypes that are now frequently attached to the smoker, such as “weak-willed”, “outcasts” and “lepers”, and abusers of public services.^{4, 5}

Participants talked about smoking as a way to survive the conditions of being stigmatized.

This study revealed tremendously powerful narratives that illustrate the importance and really the need for a critical public health approach to tobacco, and I could talk for hours about the many themes that emerged from this study related to our study aims. But so I can also give examples from a second study, today I’m just going to share one theme from this project that emerged as especially salient for many of our participants.

And here is where it becomes clear: the “why bother” of a critical public health approach. The theme that I want to highlight today is one of survival. Frequently when participants talked about their reasons for smoking, they emphasized how smoking was a way to survive the conditions of being stigmatized.

For example, next we have a quote from Ana, a 20-year-old current smoker who identifies as a queer non-binary femme person and as bisexual. They said…

So here we see this emphasis on how marginal access to health care resources positions smoking as an accessible and effective survival strategy. And for Ana and other participants, smoking becomes perceived in some ways as a harm reduction strategy for surviving in the present, running counter to mainstream public health discourse that situates smoking in relation to its future risk of tobacco-related illnesses.

Here’s a similar quote, this time from K, a 27-year-old queer and gay woman who was a current smoker and in an intensive outpatient mental health program. Like Ana, K emphasized the important role smoking played as a way to reduce harm in order to prevent suicide and self-harm. She talked about how the way she perceived anti-tobacco messages was related to her experiences, saying:

Efforts focused on the individual behavior of smoking, instead of the structural issues that contribute to smoking, may miss their mark.

K illustrates how tobacco control efforts which focus on the individual behavior of smoking, instead of the structural issues that contribute to smoking, may miss their mark for many queer smokers.

When thinking about tobacco prevention from this lens, might it not seem twisted to spend so much effort to discourage or even prohibit the use of a product perceived as the only accessible form of self-care within a society that appears to disregard the underlying causes that result in one’s need for self-care in the first place? This sentiment really demonstrates participants’ awareness of how they are positioned within larger structures that they see as threatening to their well-being and also influential in their tobacco use.

As a way to encapsulate the “why bother” of a critical public health, next is Ana again who very simply articulated their perception about the explicit use of denormalization in tobacco control. Ana said…

Now moving on to perhaps our more controversial project in the tobacco field, the e-cigarette study funded in 2015 by the California Tobacco-Related Disease Research Program. When I found out that this study had been funded, my research team almost had to give me oxygen because the critical aims of our study were going to be situated within a highly politicized and highly publicized controversy surrounding how we should be thinking about e-cigarettes within public health.

On one side we have researchers, activists, and practitioners who may be described as taking a precautionary approach to e-cigarettes, which is essentially a “guilty until proven innocent” perspective, and I would argue that this perspective has great traction in California.¹⁰ At the time of funding for our project, there were a number of efforts to dissuade any use of e-cigarettes. For example, a highly visible media campaign refers to e-cig vapor as “toxic vapor” and that vaping is “still blowing smoke”. And this is pretty misleading given that even then, e-cigarettes were widely acknowledged to be much less harmful that combustible tobacco products like cigarettes.

So this is the context in which our project is situated. In our study we were interested in examining young vapers’ perspectives on vaping—arguably a knowledge that is quite subjugated in the e-cigarette debate. A lot of assumptions operate in the literature about why youth were adopting vaping, and whether vaping was reglamorizing smoking and threatening successful denormalization efforts. And these assumptions were the ones that we wanted to investigate by examining the perspectives of youth, so that we could query the status quo operating within the tobacco field.

For our study, we interviewed 52 young people between the ages of 15 and 25, to examine the meanings, roles, and practices of nicotine and tobacco use for youth and young adults. All participants had vaped at some point in the past, and 33 participants were currently vaping at the time of the interview.

Dual users in our study overwhelmingly emphasized the utility of dual use. Vaping wasn’t considered cool but instead vaping alongside of smoking helped to reduce their risk from smoking. Which is arguably the exact opposite of what is commonly argued in public health discourses. For example, Z, a 20-year-old dual user who started smoking at the age of 15, always felt that cigarettes were bad for her and so, around 17 or 18, she picked up vaping because she heard it was healthier. She said:

For many of the young dual users in our study, starting on a path towards smoking cessation by integrating vaping was important because quitting smoking “cold turkey” had not worked for them.

Waffles, a 21-year-old dual user who began smoking at the age of 14, had always associated vaping with “hipster scum,” as she called them, which she described as people from a “higher class trying to emulate a lower class” and so she wasn’t interested in vaping. However, after trying vaping for social reasons, she too eventually adopted the practice for smoking cessation. She said:

Substance use is often considered a problem to be solved by the surveillance of youth.

The ways in which young dual users in our study talked about vaping for smoking reduction and/or cessation are pretty straightforward, and perhaps not surprising. In a recent Annual Review of Public Health article, Abrams and his colleagues have even argued, that “smokers’ complete displacement of cigarettes can take time, and a period of dual use is expected and can be acceptable along the path to smoking cessation.” ¹ This is precisely in line with how our participants are conceptualizing their own dual use.

Narratives from our study are also particularly compelling against the backdrop of tobacco prevention and policy discourses where typically any nicotine and tobacco use among youth is considered excessive. This may be due to explicit goals in tobacco control to eradicate all nicotine and tobacco use, and see preventing uptake among youth as crucial for achieving the “tobacco endgame.” This is not a particularly unusual strategy when discussing any form of drug use among youth, including alcohol and illicit drugs. It is often considered a social problem to be solved by the surveillance of youth and regulation of the products themselves.

We need a more critical approach to tobacco research in the United States.

Though our e-cigarette study was just wrapping up when these new laws went into effect, we nevertheless have evidence that raises questions about whether Tobacco 21 laws may have negative consequences for some young smokers who had been relying on e-cigs to transition away from smoking. For example, one 18-year-old participant told us that he could no longer easily access nicotine juice so he had just returned to smoking because cigarettes were easier to get. So if this narrative is illustrative of the experiences of many other young smokers, then our perhaps well-intentioned efforts might be working against their own goals.²

I hope I’ve provided some compelling examples to illustrate the what is and the why bother with a critical public health. We need more research that takes a critical approach to studies of tobacco in the United States. And not only that but it’s also important that this more critically-oriented research is a part of the conversation in developing innovative tobacco prevention and policy efforts that are sensitive to the experiences of people who continue to smoke.

It’s time to rethink public health interventions.

As Judith Green has argued in a different context, it’s time to “move away from tightly monitored outcomes” — like smoking, for our purposes — “and towards processes that will enable rethinking the sites of interventions. If we accept that inequalities in health are caused by inequalities in societies, it is perverse to continue to focus interventions and research at the very groups that have the least power: the poor, the marginal and the vulnerable.”

This might mean focusing on access to health care to equitably provide resources for mental and physical health to reduce the saliency of smoking-for-survival for some people. Or this might mean making less risky nicotine products more accessible to facilitate their use over combustible tobacco products that are far more risky, rather than treating all nicotine and tobacco products similarly. But regardless of the solution, let’s not forget that public health professionals hold power in setting the agenda and that it’s in part the perspectives of the publics that we will ultimately learn from, because those perspectives will help us to challenge the status quo in public health and think critically about what form our agendas should take.