The what is and why bother with a critical public health (085)

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

The what is and why bother with a critical public health (08)

The what is and why bother with a critical public health (08)

Black and yellow image showing quote from California Tobacco Control Program: "The goal of the California tobacco Control Program is to change the social norms surrounding tobacco use by 'indurectly 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.'"

California Department of Public Health, Tobacco Control Program Priorities

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.'”

The what is and why bother with a critical public health (09)

The what is and why bother with a critical public health (09)

Banner image from smokefree.gov site targeting LGBTQ+ groups, youth holding rainbow flag, reads "Strong enough to quit" and "This Free Life"

LGBTQ: A priority population (via smokefree.gov)

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.

The what is and why bother with a critical public health (025)

The what is and why bother with a critical public health (025)

Quote from L. Harvey book, "Knowledge is a process of moving towards an understanding of the world and of the knowledge which structures our perceptions of that world."

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 what is and why bother with a critical public health (05)

…And that we, in public health, must be critical of the status quo within our fields, which emerge from this socially-structured body of research. Judith Green has argued about the need “for critical research which reflexively unpacks its own normative assumptions,” meaning we should:

  • 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

The what is and why bother with a critical public health (06)

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.

And not just by highlighting how their experiences are interpreted through the lens of the researcher, but instead, to the best of our ability, how the experiences of the publics are interpreted by the publics themselves.

For the rest of the presentation, I’d like to discuss two of our ongoing projects that I hope will serve to illustrate what is a critical public health approach in practice, and why it’s important.

The what is and why bother with a critical public health (07)

The what is and why bother with a critical public health (07)

Image of stubbed out cigarettes with superimposed text reading "Why do LGBTQ adults tend to smoke at higher rates?"

Why do LGBTQ adults tend to smoke at higher rates?

The first project, titled LGBTQ Adults and Tobacco-Related Stigma, is a large-scale, primarily qualitative study funded by the National Cancer Institute.

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.

The what is and why bother with a critical public health (015)

The what is and why bother with a critical public health (015)

  • 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?

These are the sorts of questions that a critical public health asks.

The what is and why bother with a critical public health (04)

The what is and why bother with a critical public health (04)

Black and yellow slide, reads "Question our own practices + Be an ally"

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…