Hi. My name is Tamar Antin, and I'm the Director of the Center for Critical Public Health.
It is absolutely my pleasure to be here today, to be a part of a conference
whose theme is "Never Neutral: Resistance, Persistence and Insistence," with an explicit focus on
critical engagement. Now of course it's not me but you who are the experts on debates surrounding
surrounding information accuracy, access to information, and threats to information privacy. But what
I hope to offer you today here at the SALIS conference is some discussion of what it means to critically engage
within the public health research field, and with the knowledge that is produced there,
and also to describe what value a critical public health approach brings to the table.
To one degree or another, all of us here today operate within the domain of public health
and therefore we share some understanding about what public health is, and should do.
Typically, public health is defined as "promot(ing) and protect(ing) the health of people and
the communities where they live, learn, work and play." This is just taken from the APHA website. On the surface,
this is pretty uncontroversial. It's straightforward, might be a bit vague, but it's a straightforward description of what public health
practitioners, researchers, librarians, and policymakers are all working towards.
But upon closer reflection, maybe there are some questions that we should be asking. Like first, 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.
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, 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.
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 an understanding of the knowledge which structures our perceptions of that world."
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 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. And by doggedly
pursuing strategies that are defined by our existing knowledge, what the orthodoxy thinks
is important for protecting and promoting people's health—we may fail some groups
of people.
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.
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."
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 how highlighting 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 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. 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, and 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. The quote on this slide 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."
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.
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. And 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.
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 2015 California Adult Tobacco
Survey suggest that sexual minority adults smoke more than twice as much as heterosexuals
in the state -- 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 also twice as likely to use cigarettes
compared with cisgender adults (that is adults whose gender identity corresponds to their
sex assigned at birth). So the evidence suggests that these groups of adults are much more
likely to smoke compared to cisgender, heterosexual adults—and 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 to consider 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.
We became interested in examining perceptions of smoking-related stigma among LGBTQ Adults
who currently or formerly smoked, and who would theoretically be exposed to smoking-related
stigma. 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 or intersect with the other stigmas that 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?
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, here 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 for people who experience social
and structural marginalisation. And we see here 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 another similar quote, this time from K, a 27-year-old queer and gay woman
who is a current smoker, and at the time of our study was 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."
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 encapsulate the "why bother" of a critical public health, here 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 feel like this quote says it all. 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 the next study, perhaps our more controversial project in the tobacco field, the e-cigarette
study. This project was 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, at least. 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 to be honest this is
pretty misleading given that even then, e-cigarettes were widely acknowledged to be much less harmful
that combustible tobacco products like cigarettes. Increasingly however, the debate is now much more nuanced,
though I would argue in California, at least, e-cigarettes can still be a very polarizing
subject. And the precautionary approach still seems to dominate the public health agenda,
which arguably is evidenced in the ways in which e-cigarettes are regulated in California,
in that they are treated the same as all tobacco products in spite of their diminutive level
of risk, and evidence suggesting that they may be instrumental in helping people quit
smoking.
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. 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.
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.
The analysis that I want to share with you today is based on the dual users in our study, that
is those people who were currently smoking and vaping at the same time. Of the 33 current
vapers in the study, 29 of them were dual users, so essentially the majority. The reason that I
want to focus on this group of people is because of one particular controversy in the field
about dual use. 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 reglamorizing 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.
Our analysis of participants' narratives suggests that dual users in our study overwhelmingly
emphasized strong beliefs about the utility of dual use. Vaping wasn't considered cool
but instead vaping alongside of their smoking helped them 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 in our study, 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."
The ways in which young dual users in our study talking about vaping for smoking reduction
and/or cessation are pretty straightforward, and perhaps not surprising. And, 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." And this is
precisely in line with how our participants are conceptualizing their own dual use.
Narratives from participants in 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. And, 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
the regulation of the products themselves.
And, 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 very
often fail to accommodate the perspectives and the 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.
Though our e-cigarette study was just wrapping up when these new laws went into effect, we
nevertheless have some 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 young 18-year-old participant told us that
he could no longer easily access nicotine juice to refill his vape so he had just returned
to smoking cigarettes because they 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.
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. As Judith Green has argued in a different context, she says 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 that might 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 some power in setting the agenda and that
it's in part the perspectives of the publics who 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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