The what is and why bother with a critical public health

The what is and why bother with a critical public health

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The what is and why bother with a critical public health (27)

References & Resources

For more resources, check out our Zotero group list of Readings in Critical Public Health.

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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.

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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.

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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.

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…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.

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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.

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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.”

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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.”

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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.