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.
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.
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.
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…
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:
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.
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…
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?
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