The what is and why bother with a critical public health (18)

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.

The what is and why bother with a critical public health (17)

The what is and why bother with a critical public health (17)

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.

Image from "Still Blowing Smoke" campaign showing clod of vapor, titled "Health", text reads "Some call e-cigs healthier. Sure, if inhaling toxic chemicals sounds healthy to you. Read on to learn about the health risks of e-cigs, and find out why 'harmless water vapor' is the most inaccurate description ever."

From the California Department of Public Health’s “Still Blowing Smoke” campaign

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.

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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.

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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…

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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.

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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.

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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…

The what is and why bother with a critical public health (11)

The what is and why bother with a critical public health (11)

Image of rainbow against misty sky with text, "How do LGBTQ adults' life experiences intersect with California tobacco control?"

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?

The what is and why bother with a critical public health (10)

The what is and why bother with a critical public health (10)

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

Black and yellow slide, reading "weak-willed, outcasts, lepers, abusers of public services, selfish and thoughtless, unattractive, undesirable housemates, addicts"

Smoking-related 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

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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.