On the surface, this is pretty uncontroversial. It’s straightforward — might be a bit vague, but it’s a straightforward description of what people in the public health field are all working towards. But upon closer reflection, maybe there are some questions that we should be asking, like…
What does health mean?
Might there be multiple definitions of health depending upon who is doing the defining?
So then who gets to define health? And if someone’s definition is considered superior, then the process of defining health is political, no?
Who gets to determine how to best “promote” and “protect” someone else’s health?
What does it mean to protect another person’s health?
Now, of course, all research has elements of critique. Academics love critiquing their peers. And, critique, of course, is an important part of the process for producing scientific knowledge.
But to do critically-engaged research is different. A critical approach to public health research engages more explicitly with the politics of 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
Harvey, L 1990. Critical Social Research. London: Routledge (pp. 3-4)
In this way, critique is a thread that links all stages of a critical public health research process.
As Lee Harvey wrote in his book Critical Social Research, “For critical methodologists, knowledge is a process of moving towards an understanding of the world, and of the knowledge which structures our perceptions of that world.” 13
So let’s stop talking in the abstract. By thinking about knowledge in this way, at least two things have come to define our research — and I’ll give examples throughout the rest of the presentation to make this argument more concrete.
The publics’ experiences ≠ The lens of the orthodoxy
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.
Question our own practices + Be an ally
The second thing that in part defines the work of the Center for Critical Public Health, is making central the fact that public health knowledge emerging from research is also socially constructed.
Now I’m not arguing against the existence of facts — I’m not completely postmodern in that way.
But what I am suggesting is that the nature of our research, the questions that we ask and don’t ask, the literature that we cite and don’t cite, the interpretations of our analyses, the nature of the recommendations we make in public health, are very much socially structured…
Question what come to be defined as public health problems
Be open to alternative ways of thinking about health
Acknowledge that by promoting one facet of health, unintended consequences may arise for other facets of health.
Judith Green goes on to emphasize that “Health is multiple: and different organisations, publics and individuals, will inevitably prioritise different processes and outcomes.” 11
People who are in positions of power typically get to define the public health agenda.
But in reality, it is the people who are in positions of power who typically get to define the agenda in how to best protect and promote health. In critical public health we argue that we need to prioritize the perspectives of the publics more, especially those who have less institutional power.
In this study we conducted on average two-and-a-half-hour hour long interviews with 201 self-identifying sexual and gender minority adults who either currently or formerly smoked cigarettes.
People who smoke are much more likely to be socially and materially disadvantaged.
It’s important to remember that our sample of adults is not representative of all sexual and gender minorities in California. First this wasn’t a random sample of LGBTQ adults in the state, but more importantly, to be eligible to participate in the study, participants had to be current or former smokers.
There is a clear social gradient in smoking where people who smoke are much more likely to be socially and materially disadvantaged. So it shouldn’t be surprising that our participants’ lives were shaped by multiple interlocking systems of oppression, including sexism, heterosexism, classism, and racism. It’s these systems of oppression that are foregrounded in a critical public health.
This study was framed within the context of tobacco denormalization, which is an approach to tobacco control that pioneered in California in the late 1980s and is defined in part by its explicit focus on the use of stigma as a tobacco control strategy.
This quote is taken directly from the California Tobacco Control Branch’s website: “The goal of the California Tobacco Control Program is to change the social norms surrounding tobacco use ‘by indirectly influencing current and potential future tobacco users by creating a social milieu and legal climate in which tobacco becomes less desirable, less acceptable, and less accessible.'”
Reductions in smoking have not been experienced equitably.
So in essence, one goal is to make tobacco use, particularly smoking, socially unacceptable. Since California implemented these priorities in tobacco control, the prevalence of smoking at the population level has decreased substantially.3, 16
However, those reductions haven’t been experienced equitably. In California, where denormalization has defined the tobacco control agenda for almost three decades, smoking is now concentrated among groups who are among the most marginalized in our society.
Sexual and gender minorities make up one such group—though let’s not forget how diverse this so-called group is and that this group is made up of people with multiple and intersecting identities.6, 14, 15
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
How do LGBTQ adults’ life experiences intersect with California tobacco control?
We became interested in examining perceptions of smoking-related stigma among LGBTQ adults who currently or formerly smoked. We also wanted to explore how LGBTQ adult former and current smokers experience tobacco-related stigma, how they talk about or make sense of their smoking, what role smoking plays in their lives, and how they perceive of tobacco control strategies that aim to make smoking socially unacceptable.
We were especially interested in the intersections of stigma, so how smoking-related stigma might interact with the other stigmas our participants had to deal with, like the stigma associated with being a sexual and/or gender minority, the stigma associated with being a racial minority, or being homeless, or living in poverty. Could that shed light on why it appears that tobacco denormalization is less effective for this group of smokers?
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…
Working class people, folks of color and queers and god forbid if you are all three of those things, you are going to be smoking. You are stressed out. There are not a lot of things that are accessible for you in terms of relief. Like, who can afford to get a massage every week? I can’t. Who can afford to get mental health care?
Sometimes smoking a cigarette is the difference between – I don’t know, at least for me, it’s the difference between cutting myself or not… So sometimes I think it is a coping mechanism. Sometimes it is the only one and it’s the best one that people have.
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:
We have so many issues, at least in the queer community, mental health issues, and those aren’t being addressed, but we’re going to try to address self-care, or stuff that’s considered self-care, without addressing the underlying issues. Like, for me, I can see all the little anti-tobacco messages that I want. That, stacked against my own kind of internal pain, it’s not going to mean anything.
So, until the internal pain gets kind of helped, and some… issues get kind of resolved, that’s not going to be effective, for me at least. You know? … So if the point is to scare kids straight, I don’t think that necessarily works. If the point is to kind of help people get to the point where they don’t need to self-medicate as much, that would be money better spent, I think.
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…
That is so f-ing stupid! I feel socially unacceptable for being queer. Like, I already feel socially unacceptable. I feel isolated. I feel f-ed up and f-ed over… Denormalisation, like, how much more ostracised do you think you want people to feel, right? Denormalisation – literally, you are not normal. You are a freak of nature. Yesterday, I was basically called an f-ing freak of nature in my doctor’s office. He basically said, ‘what you are, is not normal.’ That is still ringing in my f-ing ears…
But it’s like, it’s not normal to smoke? It’s not normal to be hungry and jobless and houseless either, so why are we not confronting that? It’s not normal to walk around with this hyper vigilance due to being raped. And it’s not normal to walk around with this hyper vigilance due to people who are supposed to keep you safe, f-ing trying to kill you. Like, that is not normal. So why don’t you do some denormalisation strategies on f-ing police brutality and then get back to me and tell me how that goes? Oh my God! Who thought that was a good idea? That’s what I think about that. I think, gross. Gross, gross, gross. I’m going to have to smoke a big cigarette after this.
…I think that quote said it all.
As long as tobacco control efforts continue to stigmatize smoking, they may fail to reduce health inequities.
But before moving on, it is worth emphasizing that our participants’ narratives suggest that as long as tobacco prevention and control efforts continue to stigmatize smoking, we may foreclose the possibility of reducing health inequities, and ultimately fail in our attempts to promote and protect the health of queer adults who smoke.
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.
E-cigarettes can be a very polarizing subject.
Increasingly however, the debate is more nuanced, though I would argue in California, at least, e-cigarettes can still be a very polarizing subject. The precautionary approach still seems to dominate the public health agenda, which is evidenced by how e-cigarettes are regulated in CA, in that they are treated the same as all tobacco products in spite of their diminutive level of risk, and evidence that they may be instrumental in helping people quit smoking.1
The other side of the debate lies the harm minimization contingent. Those are people who see promise in e-cigarettes and argue that if we can encourage smokers to displace their habit with vaping, then the benefit to the public’s health will be tremendous.1 There’s also a sentiment among some that some risky experimentation during adolescence is highly normative and if youth can experiment with a less risky substance or have a product to stop using a more risky product, then perhaps that’s of great benefit to public health too.
How do young people use e-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.
Very little is known about dual use from the perspectives of youth themselves.
The analysis that I want to share with you today is based on the dual users in our study, that is those who were smoking and vaping at the same time. Of the 33 current vapers in the study, 29 were dual users, so the majority. The reason that I want to focus on this group is because of one particular controversy. Research suggests that dual use is a common practice of nicotine and tobacco use among youth and young adults, and so a lot of research is concerned with identifying whether vaping came first and then led to smoking, because if that’s true, then concerns about vaping re-glamorizing smoking and not operating as a cessation aid may have some traction.
However, in reality, very little is known about dual use from the perspectives of the youth themselves. What role do they perceive that dual use serves for them? We would argue that only by listening to youths’ perspectives can we begin to understand why dual use is a common practice, and how concerned we should be about vaping perpetuating nicotine addiction and sustaining smoking.
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:
“Vaping was a little bit of a conscious decision. I wanted to lower the amount of nicotine I was getting daily. I tried [to quit smoking] cold turkey before. I couldn’t do it. It was just way too hard, so I tried the e-cigarettes and the vapes. And I was ‘well, this isn’t so bad’. It was more customizable…flavors and you can control the nicotine levels. So ‘okay, I like this’. Yeah, I mean, of course, I still like cigarettes once in a while. But it’s just something about the vape that I keep coming back to…So actually, like I mostly kind of sort of moved away from the traditional cigarettes. Like I still buy a pack every now and then, but I don’t go through them as fast as I used to. Yeah, I still definitely do it…I still get the craving, but I’m more likely to reach for my vape versus a cigarette.”
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:
“I’ve been trying to quit smoking. I’m trying to transition through an e-cigarette. Because I wasn’t one of those people who could quit cold turkey, which I tried a lot of times, but it didn’t really work for me. So everyone is ‘yeah, you should try smoking with an e-cigarette’…you still get the feeling like you’re smoking, but it’s easier to quit than smoking cigarettes. So I think that’s later on what vaping became for me.”
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.
To be fair, given that early initiation of smoking is associated with long-term nicotine dependence and tobacco-related diseases, perhaps it is understandable that many practitioners and researchers have adopted a precautionary approach to tobacco control and prevention, especially for young people, as we see here with California’s new Tobacco 21 laws.
However, these top down social policy approaches are not inclusive of all voices. They often fail to accommodate the perspectives and practices of youth, and by neglecting youth’s perspectives, we may run the risk of falling short of our own goals by perpetuating smoking, not discouraging smoking, among some youth.
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.