How will e-cigarettes affect health inequalities? Applying Bourdieu to smoking and cessation

Informed choices for some, but not for others: An exploration of Australian midlife women's participation in mammography screening by social class

BACKGROUND

Population-level mammography screening for early detection of breast cancer is a secondary prevention measure well-embedded in developed countries, and the implications for women's health are widely researched. From a public health perspective, efforts have focused on why mammography screening rates remain below the 70% screening rate required for effective population-level screening. From a sociological perspective, debates centre on whether 'informed choice' regarding screening exists for all women and the overemphasis on screening benefits, at the cost of not highlighting the potential harms. We dovetail these disciplinary agendas to contextualise the factors that impact mammography screening choices, interpreting screening status through a social class lens.

OBJECTIVE

To understand how social class impacts informed choice-making among midlife women (45-64 years), regarding (non) participation in mammography screening.

DESIGN

A qualitative study using semi-structured interviews.

METHODS

We interviewed 36 Australian midlife women from differing social class groups who were 'screeners' or 'non-screeners'. We conducted a theory-informed thematic analysis and used Bourdieu's relational social class theory to consider how women's access to social, cultural and economic capital influenced their screening identities. We conducted matrix and crosstab queries across themes to identify patterns by social class. We extend the findings from Friedman's study of women's screening perspectives as 'attentional' types utilising the 'sociology of attention'.

RESULTS

Our results map to Friedman's four 'attentional' types (default or conscious interventionists, conflicted or conscious sceptics), and we show how social class impacts women's attention to screening and participation. We show for middle-class women screening is a 'given', they align closely with normative screening expectations. Working-class women who screen, do so out of a sense of compliance. Affluent non-screeners make informed choices, while working-class women are more passive in their non-screening choices, being a group that sits outside of Friedman's four attentional types.

CONCLUSION

Current approaches to screening communication and programme delivery can be improved by tailoring approaches to reflect the impacts of social class in shaping women's 'choices'. Subsequently, equitable breast cancer prevention may be afforded, which impacts positively on population-level screening rates.

Patterns and perceptions of vaping among adults living in social housing: a representative survey in Great Britain, 2023

BACKGROUND

Vaping products are effective for helping people to stop smoking and may therefore offer a potential means to reduce high rates of smoking in socioeconomically disadvantaged groups. This study aimed to examine current patterns and perceptions of vaping among people living in social housing in Great Britain compared with those living in other housing types.

METHODS

Data were from the Smoking Toolkit Study; a nationally-representative survey conducted in 2023 (n = 23,245). Logistic regression tested cross-sectional associations between living in social (vs. other) housing and current vaping among adults; vaping frequency, device type, nicotine concentration, and source of purchase among current vapers; use of vaping products as a smoking cessation aid among past-year smokers who tried to quit; and harm perceptions of vaping products relative to cigarettes among current smokers.

RESULTS

Current vaping prevalence was twice as high among adults living in social housing (19.4%) compared with those in other housing types (10.4%; OR = 2.07, 95%CI = 1.84-2.33). This was partly explained by differences in sociodemographic characteristics and smoking status; after adjustment, the odds of being a current vaper were 33% higher (ORadj=1.33, 95%CI = 1.14-1.54). Among vapers, there were no notable differences by housing tenure in vaping frequency, main device type used, usual nicotine concentration, usual source of purchase, or use as a smoking cessation aid. However, current smokers living in social housing were more likely to think vaping is more harmful than cigarettes (31.6% vs. 21.8%; ORadj=1.61, 95%CI = 1.30-1.99).

CONCLUSIONS

In Great Britain, adults who live in social housing are more likely to vape than those who live in other housing types, even after accounting for their younger age and higher smoking rates. However, misperceptions about the relative harms of vaping products and tobacco are common among smokers living in social housing. Interventions addressing these misperceptions could help encourage more people living in social housing to switch from smoking to vaping and reduce smoking-related health inequalities.

PRE-REGISTRATION

The study protocol and analysis plan were pre-registered on Open Science Framework (https://osf.io/n3mvs/).

Subculture wars: The struggle for the vape industry

Drawing on a 2-year study, I argue that the UK vape industry is engaged in a classificatory struggle between a subcultural industry and its "other", the mainstream industry. I build on Thornton's analysis of club culture to characterize the subcultural vape industry as a community of taste built round a masculine aesthetic and a commitment to authenticity and DIY practice. Its attachment to complex systems and masculine spaces risked excluding customers without specialist knowledge or interest. The mainstream industry included tobacco companies which promoted vaping as a complementary category to smoking, linking their own vaping products to historic meanings of the cigarette as a lifestyle product. This task was hampered by the toxic legacy of combusted tobacco and its increasing reversion to a generic category rather than a branded product. Finally, the success of the price-focused vaping industry has been largely overlooked, but suggests that for most consumers, electronic cigarettes are still a contrasting category to combusted tobacco and are purchased largely on price. I conclude that the exclusion of a feminized, classed "other" is a defining element of subcultural formation, itself an overwhelmingly male mechanism of group identity construction.

Place of alcohol in the 'wellness toolkits' of midlife women in different social classes: A qualitative study in South Australia

In this article, we explore how women in different social classes had differential access to resources and services to enhance their 'wellness'-resulting in classed roles in alcohol consumption. We analyse data from a qualitative study on alcohol by midlife women in South Australia and employ the analogy of a 'toolkit' in order to understand the structural patterning of 'wellness tools'. Bourdieu's relational model of class guides our exploration of women's inequitable opportunities for wellness. Higher social class women had 'choices' facilitated by bulging wellness toolkits, such as yoga, exercise and healthy eating regimens-alcohol consumption was not essential to promoting 'wellness' and did not have an important place in their toolkits. Middle-class women had less well-stocked toolkits and consumed alcohol in a 'compensation approach' with other wellness tools. Alcohol consumption received positive recognition and was a legitimised form of enjoyment, fun and socialising, which needed counterbalancing with healthy activities. Working-class women had sparse toolkits-other than alcohol-which was a tool for dealing with life's difficulties. Their focus was less on 'promoting wellness' and more on 'managing challenging circumstances'. Our social class-based analysis is nestled within the sociology of consumption and sociological critiques of the wellness industry.

From gateways to multilinear connections: A qualitative longitudinal investigation of the relationships between vaping and smoking among adolescent users

BACKGROUND

The international growth of e-cigarette use has been accompanied by a corresponding concern that e-cigarettes will act as a 'gateway' to smoking and the use of other drugs. Taking these concerns as our point of departure, we explore the relationships between vaping and smoking among a cohort of young people.

METHODS

Qualitative longitudinal methods with a diverse sample of 36 14-18-year olds from the UK city of Leicester. A total of 66 depth interviews conducted across two phases separated by 6-12 months. The interviews were recorded, transcribed verbatim and thematically analysed.

FINDINGS

We highlight a complex 'tangle' of connections between substances/risk behaviours recounted to us by our adolescent study participants, including multiple and multilinear relationships between vaping and smoking. These findings problematise some of the core axioms of the notion of gateways as an explanatory model of causality and sequential connection between smoking and vaping. They also throw into question gateway logics more fundamentally. While many of our study participants themselves consciously invoked ideas of 'gateway effects', the accounts they produced repeatedly disrupted the logics of connection (between e-cigarettes and smoking; one set of behaviours and another) presupposed in gateway theory and our own early lines of questioning. Accordingly, we explore how cultural understandings of gateway effects are invoked by users in accounting for their vaping and smoking behaviours, noting the potential influence of these ideas upon the very processes they are understood to apprehend.

CONCLUSION

Our findings suggest there is a case to be made to reinforce the distinctiveness of tobacco and e-cigarettes in the life-worlds of young people to avoid naturalising a 'gateway' logic of connection that might ultimately inform the associative logic of young users themselves, and potentially the development of their usage careers.

An Evaluation of the Knowledge and Perceptions of Pharmacy Staff and Pre-Registration Students of E-Cigarettes Use: A Systematic Review

INTRODUCTION

Pharmacy staff are a trusted source of advice on the safe and appropriate use of medicines and devices. Retail pharmacies deliver smoking cessation services and sell e-cigarettes in the UK. This review asks 'what knowledge, experience and ability do staff have to support e-cigarette users to quit smoking'.

METHODS

A systematic literature search was undertaken drawn on predefined eligibility criteria and a comprehensive search strategy following the PRISMA guideline. Eligible papers reported survey-research published in English from 2015 to 2020. PubMed, Google Scholar, OVID, EMBASE and MEDLINE Databases were searched. No restrictions on study design or language were applied. Two reviewers independently screened for inclusion/exclusion and then extracted the relevant information from the articles for synthesis.

RESULTS

Of 12 potentially eligible full-text studies, 1 was a duplicate, 7 were excluded as per eligibility criteria. Four papers were finally included in this literature review. Two studies indicated that pharmacy staff are less confident in giving advice on e-cigarette use. Knowledge on the adverse effects of e-cigarettes compared to traditional smoking cessation aids remain unclear. In one study, 42% of community pharmacists did not believe that e-cigarettes could be used for smoking cessation. Three studies identified need for specific regulations and professional support. The overall certainty of the evidence is 'low' or 'very low', with moderate levels of bias.

CONCLUSION

Pharmacists may be well placed to implement e-cigarette smoking cessation interventions, but most practitioners lacked knowledge and ability to support these customers citing unclear risk of harm. Pharmacists felt secure in recommending traditional cessation tools. Further regulation, guidelines and training is needed. Findings may be less generalizable in countries where e-cigarettes are banned. Their extent of knowledge, experience and ability to support users of e-cigarettes within their community to quit smoking is lacking.

Socio-economic distribution of e-cigarette use among recent former regular smokers and current smokers at ages 25-26 in England

BACKGROUND AND AIMS

E-cigarettes may potentially help young adult smokers to quit smoking, yet little is known about differences among socio-economic groups. We examined associations between key socio-economic characteristics and e-cigarette use among recent former smokers and current smokers in a sample of young adults in England.

DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS

We used data on 346 recent former regular (daily for 12+ months) smokers and 1913 current smokers from the ages 25-26 wave of the Next Steps cohort study (2015-2016). In multinomial logistic regression, we estimated relative risk ratios (RRR) of e-cigarette use (never, former, non-daily, daily) by educational attainment, social class [using the National Statistics Socio-economic classification (NS-SEC)] and employment status [full-time, part-time, unemployed and other 'inactivity' (e.g. stay-at-home parents and permanantly disabled)], adjusting for sex.

FINDINGS

Among recent former regular smokers, there were no patterns of association between socio-economic characteristics and e-cigarette use. Among current smokers: (1) compared with higher occupation (NS-SEC I/II), intermediate occupation (NS-SEC III/IV) was positively associated with non-daily e-cigarette use [RRR = 1.77, 95% confidence interval (CI) = 1.03-3.03]; (2) compared with full-time employment, unemployment was negatively associated with non-daily and daily e-cigarette use (RRR = 0.38, 95% CI = 0.18-0.81; RRR = 0.12, 95% CI = 0.02-0.56) and other economic inactivity was negatively associated with daily e-cigarette use (RRR = 0.39, 95% CI = 0.16-0.93).

CONCLUSIONS

Among young adult smokers in England, lower-status occupational groups were more likely to use e-cigarettes on a non-daily basis than to have never used compared with higher status occupational groups. Compared with people in full-time employment, those without employment were less likely to use e-cigarettes daily than to have never used.

Responsibility, normalisation and negotiations of harm: E-cigarette users' opinions and experiences of vaping around children

BACKGROUND

Concern about youth uptake of vaping is widespread. Regulation and education campaigns aim to protect children from initiating use, yet it is likely that children will be primarily influenced by the behaviour of people in their immediate environment. This is the first known study exploring e-cigarette users' views and reported experiences of vaping around children.

METHODS

Following informed consent, semi-structured qualitative interviews were conducted with 40 adults who had attempted to give up smoking by vaping. Participants were recruited from England as part of a wider study into e-cigarette use trajectories and smoking relapse (ECtra study). Data were extracted from 28 interviews where participants had spontaneously discussed vaping around children. Extracted data were analysed thematically and situated in previous analysis of vaping identity which distinguished between recreational and medicinal vapers.

RESULTS

Vaping behaviour around children was in part a habituated replication of smoking norms but also guided by broad vaping identity; recreational users were more permissive and medicinal users more secretive. Vaping in the home appeared to be determined by caregivers' need to reconcile vaping behaviour so that it was congruent with parental identity as a responsible caregiver. Participant perspectives reflected existing moral discourses applied to e-cigarettes around the use of "harm reduction for smokers" and "potential for youth harm".

CONCLUSION

Vaping is likely to be role modelled within the community and home despite attempts by e-cigarette users to conceal the behaviour. The ambivalent contextualisation of e-cigarettes means that e-cigarette users may lack a clear narrative to draw on when discussing vaping with children. Public health guidance for vaping around children could be helpful, but to be most effective, should take into consideration users' vaping identity.

Association of Socioeconomic Position With e-Cigarette Use Among Individuals Who Quit Smoking in England, 2014 to 2019

Importance

e-Cigarette use among individuals who quit smoking more than 1 ago in England is highest among those with lower socioeconomic position and may affect smoking-related health inequalities, depending on whether the devices protect against relapse to tobacco smoking.

Objectives

To assess trends in current e-cigarette use by socioeconomic position among individuals who have quit smoking for at least 1 year, to capture postcessation initiation among those who quit within the past year and did not use an e-cigarette in their most recent quit attempt (representing recent initiation), and to capture postcessation initiation among those who quit smoking before e-cigarettes became popular in 2011 (representing late initiation).

Design, Setting, and Participants

This cross-sectional study of 34 442 adults (≥16 years) who formerly smoked used data from the Smoking Toolkit Study (conducted 2014-2019), a nationally representative, monthly, repeated, cross-sectional, household survey of smoking and smoking cessation in England. Data analysis was conducted in December 2019.

Exposures

Socioeconomic position based on occupation.

Main Outcomes and Measures

Current self-reported e-cigarette use.

Results

Weighted samples consisted of 19 297 individuals who had quit smoking for at least 1 year (mean [SD] age, 59.2 [17.0] years; 9024 [46.8%] women), 904 who quit in the past year and did not use an e-cigarette in their most recent quit attempt (mean [SD] age, 41.6 [17.1] years; 445 [49.3%] women), and 14 241 who quit before 2011 (mean [SD] age, 63.6 [14.6] years; 6619 [46.5%] women). Among those who had quit smoking fot at least 1 year, e-cigarette use increased from 3.3% (95% CI, 2.7%-4.0%) in 2014 to 10.4% (95% CI, 9.2%-11.6%) in 2019 among all socioeconomic groups. Use was more common among those with lower socioeconomic position than those with higher socioeconomic position (odds ratio, 1.59; 95% CI, 1.05-2.40; P = .03). Regarding postcessation initiation of e-cigarettes, among those who quit smoking in the past year and did not use an e-cigarette in their most recent quit attempt, 7.1% (95% CI, 5.9%-9.3%) initiated e-cigarette use after smoking cessation, and there was no clear trend over time or any difference according to socioeconomic position. Among those who quit before 2011, there was an overall increase in use of e-cigarettes (0.8% [95% CI, 0.5%-1.2%] in 2014 to 2.1% [95% CI, 1.4%-2.8%] in 2019), but there were no apparent differences in use across socioeconomic position.

Conclusions and Relevance

In this study, e-cigarette use increased among all participants from 2014 to 2019 but was highest among those with lower socioeconomic position. Continued monitoring of this socioeconomic patterning is important because if e-cigarettes do not confer the public health benefit of protection against relapse to smoking, then equity-negative disadvantages of long-term usage are more likely. Late, but not recent, postcessation initiation of e-cigarettes has increased over time but is not likely to affect smoking-related health inequalities because there were no differences by socioeconomic position.

Explaining the social gradient in smoking and cessation: the peril and promise of social mobility

Smoking in high-income countries is now concentrated in poor communities whose relatively high smoking prevalence is explained by greater uptake but above all by lower quit rates. Whilst a number of barriers to smoking cessation have been identified, this is the first paper to situate cessation itself as a classed and cultural practice. Drawing on ethnographic research carried out in a working-class community in the North of England between 2012 and 2015, I theorise smoking cessation as a symbolic practice in relation to the affective experience of class and social mobility. I show that ambivalence about upward mobility as separation and loss translated into ambivalence about smoking cessation. The reason for this was that the social gradient in smoking operated dynamically at the level of the individual life course, i.e. smoking cessation followed upward mobility. A serious health problem was an appropriate reason to quit but older women continued to smoke despite serious health problems. This was linked to historical gender roles leading to women placing a low priority on their own health as well as the intergenerational reproduction of smoking through close affective links with smoking parents.

Potential for non-combustible nicotine products to reduce socioeconomic inequalities in smoking: a systematic review and synthesis of best available evidence

BACKGROUND

While some experts have emphasised the potential for e-cigarettes to facilitate cessation among smokers with low socioeconomic status (SES), there is limited evidence of their likely equity impact. We assessed the potential for electronic cigarettes and other non-combustible nicotine-containing products (NCNPs) to reduce inequalities in smoking by systematically reviewing evidence on their use by SES in countries at stage IV of the cigarette epidemic.

METHODS

Ten electronic databases were searched in February 2017 using terms relating to e-cigarettes, smokeless tobacco and nicotine replacement therapy (NRT); and SES. We included studies published since 1980 that were available in English and examined product use by SES indicators such as income and education. Data synthesis was based on those studies judged to be of medium- to high-quality using guidelines adapted from the Critical Appraisal Skills Programme.

RESULTS

We identified 54 studies describing NCNP use by SES across 12 countries, of which 27 were judged of sufficient quality to include in data synthesis. We found mixed patterns of e-cigarette current use by SES, with evidence of higher use among low-income adults but unclear or mixed findings by education and occupation. In contrast, smokeless tobacco current use was consistently higher among low SES adults. There was very limited evidence on the SES distribution of NRT in adults and of all NCNPs in young people.

CONCLUSIONS

The only NCNP for which there are clear patterns of use by SES is smokeless tobacco, where prevalence is higher among low SES groups. While this suggests a potentially positive impact on inequalities in smoking (if NCNP use displaces smoked tobacco use), this has not been seen in practice. These findings do not support the suggestion that e-cigarettes have the potential to reduce social inequalities in smoking, since i) current evidence does not show a clear trend of higher e-cigarette use in population groups with higher tobacco consumption, and ii) the experience of smokeless tobacco suggests that - even where NCNP use is higher among low SES groups - this does not necessarily replace smoked tobacco use in these groups.

Nicotine addiction as a moral problem: Barriers to e-cigarette use for smoking cessation in two working-class areas in Northern England

Tobacco use in high-income countries correlates with socio-economic disadvantage, but although switching to electronic cigarettes could be a safer alternative, little is known about barriers to use. Drawing on eighteen months of data collection in two areas of Northern England in 2017/18 including ethnography and interviews with 59 smokers and e-cigarette users, I show that concern about continued nicotine addiction either deterred working-class smokers from switching to e-cigarettes or dictated the conditions of their use. Research participants were unhappy about addiction both as loss of control experienced as moral failure and as neglect of financial responsibilities i.e. role performance failure in relation to family responsibilities, or what I call ‘thrift as care’. They reduced the moral burden of addiction by lowering nicotine content, rejecting pleasure and minimising expenditure. They chose the cheapest possible tobacco, switched from combusted tobacco to cheaper e-cigarettes and bought cheap e-cigarettes and liquids. For working-class smokers, minimising spend on what they perceive negatively as addiction may be a greater moral concern than reducing health risk. I conclude that ensuring that vaping is significantly cheaper than smoking may be key to addressing health inequalities linked to tobacco use.

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Working-class smokers avoided e-cigarettes because of concern about addiction.

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Those who did switch preferred a medical to a recreational model of use.

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Users reduced nicotine content, minimised spending and avoided exotic flavours.

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Failure of willpower and role performance (thrift as care) created addiction shame.

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Ensuring that vaping is cheaper than smoking is key to harm reduction.

Association between tobacco control policies and current smoking across different occupational groups in the EU between 2009 and 2017

BACKGROUND

This study investigated the cross-national and longitudinal associations between national tobacco control policies and current smoking in 28 European Union (EU) member states between 2009 and 2017. It also examined the interaction between tobacco control policies and occupational status.

METHODS

We used data from four waves of Eurobarometer (2009, 2012, 2014 and 2017). The total sample size was 105 231 individuals aged ≥15 years. Tobacco Control Scale (TCS) scores (range 0 to 100) for years 2005, 2007, 2012 and 2014 measured the strength of country-level tobacco control policies. Logistic multilevel regression analyses with three levels (the individual, the country-year and the country) were performed with current smoker as the dependent variable.

RESULTS

Across the EU, average smoking prevalence fell from 29.4% (95% CI 28.5% to 30.2%) in 2009 to 26.3% (95% CI 25.4% to 27.1%) in 2017. We confirmed that cross-nationally, strong national tobacco control policies are significantly associated with a low probability of smoking. A one-point increase in TCS score was associated with lower odds of smoking (OR=0.990; 95% CI 0.983 to 0.998), but longitudinally (within-country) increases in TCS were not associated with current smoking (OR=0.999; 95% CI 0.994 to 1.005). Compared with those in manual occupations, the cross-national association was stronger in the upper occupational group (conditional OR for the interaction=0.985; 95% CI 0.978 to 0.992) and weaker in the economically inactive group (conditional OR for the interaction=1.009; 95% CI 1.005 to 1.013).

CONCLUSION

Differences in tobacco control policies between countries were associated with the probability of smoking but the changes in TCS within countries over time were not. Differences between countries in tobacco control policies were found to be most strongly associated with the likelihood of smoking in the highest occupational groups and were found to have only a weak association with smoking among the economically inactive in this sample.