Young adults' experiences of neighbourhood smoking-related norms and practices: A qualitative study exploring place-based social inequalities in smoking

Association between psychosocial factors and co-morbid cigarette smoking and alcohol use in a population experiencing homelessness

The prevalence of combustible cigarette smoking in populations experiencing homelessness in the United States is five times that of the general population. The psychosocial well-being of persons who smoke and experience homelessness is poorer if such persons also use alcohol heavily. The PTQ2 study was a randomized clinical trial among persons experiencing homelessness who were also current smokers and heavy alcohol consumers. Secondary data analysis of the PTQ2 baseline data was conducted to examine associations among psychosocial variables (anxiety, depression, hopelessness, social network size), heaviness of smoking (cigarettes/day) and alcohol consumption (drinking days/month), and duration and frequency of homelessness. Among the 420 participants, the majority were male (75%), black (70%) and non-Hispanic (94%) with a mean age of 46.6 years (SD = 11.6).  Bivariate analyses show that heaviness of smoking was positively correlated with social network size (r = 0.16, p = .001). Heaviness of drinking was positively correlated with the MINI anxiety score (r = 0.13, p = .009) and marijuana use (median total number of drinks in past 30 days among those who used marijuana in past 30 days vs. did not use: 50 vs. 24, p < .0001), and associated with frequency of homelessness (median total number of drinks in past 30 days among those experiencing homelessness once vs. >1 time: 30 vs. 44, p = .022). The findings highlight the psychosocial factors that warrant consideration when addressing heavy smoking and alcohol consumption in persons experiencing homelessness.

Factors sustaining legitimacy of smoking in Vocational Education and Training (VET) schools: a qualitative needs assessment

BACKGROUND

Most adult smokers started smoking in their teenage years, which increases the risk of nicotine dependence. In Denmark, there is a high prevalence of youth smoking among students in Vocational Education and Training (VET). However, reducing and preventing smoking in this group is a major challenge. This article presents a needs assessment aimed to explore factors sustaining legitimacy of smoking in VET schools and consider the measures needed to prepare VET schools' implementation of smoking reduction and prevention interventions.

METHODS

Participant observations were conducted in four VET classes representing three VET schools in Denmark with a duration of four days each. Individual, semi-structured interviews were conducted with teachers, managers, and a student advisor, as well as four focus groups with a total of 20 students. Interviews were audio-taped, transcribed, and the data material was analyzed following Malterud's systematic text condensation.

FINDINGS

Factors that helped sustain legitimacy of smoking in VET schools included a positive and normalized attitude towards smoking at home and among friends, an understanding of smoking as an integral and expected practice in VET professions and schools, a perceived reliance on smoking as an icebreaker in new social relations and as a pedagogical tool, and smoking as a habit and a means to deal with boredom and stress relief.

CONCLUSIONS

The factors sustaining legitimacy of smoking in VET schools are reciprocal and call for smoking reduction and prevention intervention efforts which consider and address social influence, habitual behavior, and psychological needs, as well as changes at the policy level.

"It's nice to just be": A qualitative study on the meaning-imbued reality of waterpipe smoking among young adults in Sweden

Background and aims: Waterpipe smoking is regarded as a burgeoning public health problem due to its popularity among young adults. This study aims to understand the meaning-imbued reality of waterpipe smoking for young adults in Sweden. Method: Data from 18 individual interviews with ethnically diverse Swedish young adults were analysed using inductive latent-level qualitative content analysis. Results: The youth's experience of waterpipe smoking shows different dimensions (time, space, fun, community) that construct the practice of waterpipe smoking as a closed bubble characterised by harmlessness, cosiness and freedom to develop an adult self in the waterpipe group. The bubble provides a breathing space and timeout in everyday life, fuelled by an understanding of the hookah as hazard-free and liberating. A variety of control mechanisms are used to defend the bubble's constructed harmlessness, proving responsibility by applying practice-, communication- and Othering-oriented means. Conclusion: The study enhances the understanding of waterpipe smoking by highlighting its community- and self-forming meaning in a combined focus on ritualistic and symbolic qualities. For young adults, waterpipe smoking combines potentially beneficial and detrimental impacts on health. This complex situation requires a dialogical - rather than a traditional - approach to prevention that negotiates the risk landscape faced by young adults.

Gender Matters: Identity, Risk Perception and Preventive Interventions for Alcohol Consumption among Adolescents Using a Qualitative Approach

The epidemiological information available in Spain and the Community of Madrid highlights two relevant facts regarding alcohol consumption: an increase in binge drinking in teenagers and a reduction/reversal of the gender gap, particularly at young ages. This article aims to describe some of the factors related to alcohol use in teenagers, especially those related to gender and risk perception. A qualitative study was designed with semi-structured interviews and a discussion group with students from the city of Madrid aged 14 to 18 years. A descriptive analysis of the content of the replies of 28 teenagers was conducted. The results show that alcohol consumption has an identity component, both in terms of transition to adulthood and gender role performance. Consumption is also associated with risks, especially those determined by gender inequality, which teenagers learn to manage as a means of survival in nightlife. Preventive campaigns typically lack a gender perspective and a focus on risk prevention. To reduce the prevalence of consumption and associated risks, these strategies need to be reformulated with a gender perspective.

The implementation of a smoking cessation and alcohol abstinence intervention for people experiencing homelessness

Background

In the United States, eighty percent of the adult homeless population smokes cigarettes compared to 15 percent of the general population. In 2017 Power to Quit 2 (PTQ2), a randomized clinical trial, was implemented in two urban homeless shelters in the Upper Midwest to address concurrent smoking cessation and alcohol treatment among people experiencing homelessness. A subset of this study population were interviewed to assess their experiences of study intervention. The objective of this study was to use participants’ experiences with the intervention to inform future implementation efforts of combined smoking cessation and alcohol abstinence interventions, guided by the Consolidated Framework for Implementation Research (CFIR).

Methods

Qualitative semi-structured interviews were conducted with 40 PTQ2 participants between 2016–2017 and analyzed in 2019. Interviews were audio-recorded, transcribed, and analyzed using a socially constructivist approach to grounded theory.

Results

Participants described the PTQ2 intervention in positive terms. Participants valued the opportunity to obtain both counseling and nicotine-replacement therapy products (intervention characteristics) and described forming a bond with the PTQ2 staff and reliance on them for emotional support and encouragement (characteristics of individuals). However, the culture of alcohol use and cigarette smoking around the shelter environment presented a serious challenge (outer setting). The study setting and the multiple competing needs of participants were reported as the most challenging barriers to implementation (implementation process).

Conclusion

There are unique challenges in addressing smoking cessation with people experiencing homelessness. For those in shelters there can be the difficulty of pro-smoking norms in and around the shelter itself. Considering pairing cessation with policy level interventions targeting smoke-free spaces, or pairing cessation with housing support efforts may be worthwhile.. Participants described a discord in their personal goals of reduction compared with the study goals of complete abstinence, which may pose a challenge to the ways in which success is defined for people experiencing homelessness.

Trial registration

Clinicaltrials.gov, NCT01932996, registered 08/30/2013.

While Some Things Change, Do Others Stay the Same? The Heterogeneity of Neighborhood Health Returns to Gentrification

Gentrification is associated with decreases in neighborhood poverty and crime, increases in amenities and services, among other benefits-all identified as structural determinants of health. However, gentrification is also associated with population-level replacement of the existing community, or threats thereof. Combining census data from the ten largest MSAs in the U.S. with tract-level estimates from the CDC-PLACES Project from 2013-14 to 2017-18, we explore how the changing socioeconomic conditions in gentrifying neighborhoods correlate with changes in neighborhood health. We find significant differences between gentrifying and non-gentrifying neighborhoods in their associations with neighborhood health. The sociodemographic changes occurring in gentrifying neighborhoods generally correspond with simultaneous decreases in aggregate health risk behaviors and negative health outcomes. However, these changes are heterogeneous and complex. Whether and how neighborhood health changes alongside other components of neighborhood change depends on whether gentrification occurs in majority Black, Hispanic, or White neighborhoods. Our findings provide preliminary evidence that the changes accompanying gentrification extend to neighborhood health, but the direction of influence varies by neighborhood composition, type of sociodemographic change, specific health outcome, and spatial spillover. We discuss theoretical implications for future work addressing the mechanisms driving changes in neighborhood health, and potential approaches that differentiate policy responses.

Tobacco use, smoking identities and pathways into and out of smoking among young adults: a meta-ethnography

BACKGROUND

This meta-ethnography investigates how young adults describe their tobacco use, smoking identities and pathways into and out of regular smoking, to inform future smoking prevention and harm reduction interventions.

METHODS

Eight databases were systematically searched using keywords and indexed terms. Studies were included if they presented qualitative data from young adults aged 16-25 reporting smoking histories and/or smoking identities from countries culturally similar to the UK. A systematic and rigorous meta-ethnographic approach was employed, consistent with Noblit and Hare's methodology.

RESULTS

Thirty papers were included. Reasons stated for taking up smoking and becoming a smoker included alleviating stress, transforming one's identity, and coping with the transition to further education, employment or leaving home. Many used smoking to aid acceptance within new peer groups, particularly when alcohol was present. Smoking was also perceived as an act of resistance and a coping mechanism for those with marginalised identities. Barriers to quitting smoking included young adults' minimisation or denial of the health risks of smoking and not identifying with "being a smoker".

CONCLUSIONS

This meta-ethnography may provide a blueprint to inform the development of health and wellbeing interventions designed specifically for young adults. Smoking cessation interventions should be co-designed with young adults based on their perceived needs, resonant with their desire to quit in the future at key milestones. Harm reduction interventions should address the social aspect of addiction, without reinforcing stigma, particularly for those with marginalised identities.

Socioeconomic inequalities in secondhand smoke exposure before, during and after implementation of Quebec's 2015 'An Act to Bolster Tobacco Control'

BACKGROUND

To better understand whether tobacco control policies are associated with changes in secondhand smoke (SHS) exposure across socioeconomic groups, we monitored differences in socioeconomic inequalities in SHS exposure in households and private vehicles among youth and adults before, during and after adoption of Quebec's 2015 An Act to Bolster Tobacco Control.

METHODS

Using data from the Canadian Community Health Survey, we examined the prevalence of daily exposure to SHS in households and private vehicles among youth (ages 12 to 17) and adults (ages 18+) across levels of household education and income (separately) in 2013/2014, 2015/2016 and 2017/2018. We tested differences in the magnitude of differences in outcomes over time across education and income categories using logistic models with interaction terms, controlling for age and sex.

RESULTS

We detected inequalities in SHS exposure outcomes at each time point, most markedly at home among youth (OR of SHS exposure among youth living in the 20% poorest households vs the 20% richest=4.9, 95% CI 2.7 to 6.2). There were decreases in SHS exposure in homes and cars in each education/income group over time. The magnitude of inequalities in SHS exposure in homes and cars, however, did not change during this period.

CONCLUSIONS

The persistence of socioeconomic inequalities in SHS exposure despite implementation of new tobacco control laws represents an increasingly worrisome public health challenge, particularly among youth. Policymakers should prioritise the reduction of socioeconomic inequalities in SHS exposure and consider the specific needs of socioeconomically disadvantaged populations in the design of future legislation.

Social measures for reducing exposure to secondhand smoke in migrant workers of sugarcane harvest in the lower northern region of Thailand

INTRODUCTION

The sugarcane harvest migrant workers are an underprivileged group in Thailand and have a high risk of exposure to secondhand smoke but are potentially neglected in health promotion interventions.

METHODS

This three-phase study applied a mixed-method research approach. The data were collected from February to December 2019 from the Sukhothai province of Thailand. In Phase 1, the level of secondhand smoke exposure of the sugarcane harvest migrant workers at the worker camp was explored. The data were collected from 462 workers by questionnaires and from 24 sample participants in the group discussions about the factors leading to the exposure to secondhand smoke. Phase 2 was the provision and implementation of social measures for the health protection of migrant workers and families from exposure to secondhand smoke. In Phase 3, an evaluation of the health protection model for the migrant workers and families from secondhand smoke exposure was explored.

RESULTS

Workers aged ≤40 years had 1.9 times higher exposure to secondhand smoke than workers aged ≥41 years (OR=1.93; 95% CI: 1.24–3.01). Those who worked overtime had 1.7 times higher exposure to secondhand smoke than those who did not work overtime (OR=1.71; 95% CI: 1.10–2.66). Social measures to prevent secondhand smoke were: given a warning, no rewards for cigarettes, designated smoking area, not asking the children to buy cigarettes, stop displaying cigarettes at grocery shops, and empowering woman to go against the smoking husband in the camp and the sugarcane field when the women, children, and nonsmokers are present. After implementing the measures, there was no exposure to secondhand smoke inside the room, cooking area, and at the quad in the camp center.

CONCLUSIONS

Appropriate social measures for health protection can help to reduce exposure to secondhand smoke.

Associations of Quantity Smoked and Socioeconomic Status With Smoke-Free Homes and Cars Among Daily Smokers

INTRODUCTION

An association between socioeconomic status (SES) and smoke-free private spaces among smokers could be due to heavier smoking among low SES smokers. We assessed whether quantity smoked or SES are independently associated with smoke-free homes or cars in daily smokers.

METHOD

Data were drawn from a cross-sectional telephone survey (2011-2012) of 750 daily smokers age ≥18 years in Quebec, Canada (45% response). Multivariable logistic regression was used to model the independent association between (a) number of cigarettes smoked per day, and (b) each of educational attainment, annual household income, or active employment status and smoke-free homes or cars.

RESULTS

Participants were 41.0 years old on average, 57% were female. Median (IQR) number of cigarettes smoked per day was 14 (10, 20). Forty-eight percent of participants reported smoke-free homes; 34% reported smoke-free cars. Quantity smoked was strongly associated with both smoke-free homes and cars. Income and education (but not actively employed) were associated with smoke-free homes. None of the SES indicators were associated with smoke-free cars.

CONCLUSIONS

Interventions targeting smokers to promote smoke-free homes and cars should incorporate components to help smokers reduce quantity smoked or preferably, to quit. Interventions targeting smoke-free homes will also need to address SES inequalities by education and income. Our data suggest that reduction in quantity smoked may help smokers reduce SHS exposure in cars, but that an inequality lens may not be relevant.

In-situ at a distance? challenges and opportunities for health and place research methods in a post-COVID-19 world

In-situ methodologies, including go-along and photo-elicited interviews, are ideal for harnessing people's lived experiences of place and their meanings for health and health equity. Their immersive nature means that the COVID-19 pandemic has impacted their use. Physical distancing measures combined to anxiety over the sharing of physical space have created ethical and practical challenges to the conduct of in-person in-situ methodologies. However, in-situ methodologies are precisely needed to gain deeper understandings of people's changing relationships to place post-COVID-19. In this commentary we discuss emerging challenges, highlight questions researchers should ask before engaging in these methods in the future, and explore adaptations and alternatives to traditional in-person in-situ methodologies.

Indonesian adolescents' perspectives on smoking habits: a qualitative study

Background

The prevalence of smoking among adolescents is high in Indonesia. Therefore, this qualitative research aimed to explore the perspectives of Muslim adolescents on smoking habits as a reference for developing effective prevention programs.

Methods

Three focus group discussions involving 24 junior high school male students (mean age = 13.75 years) were the main source of data for this phenomenological qualitative study. The discussion guide was developed by the researchers based on the reviewed literature and validated by experts. The research findings were analyzed using an inductive content analysis with systematic steps based on the stages of qualitative data analysis.

Results

Adolescent perspectives on smoking were grouped into two themes: perception of smoking and smoking-related factors. The perception of smoking encompassed three sub-themes: smoking as a social habit, contradictive feelings, and the Islamic perspective. The smoking-related factors included peer pressure, the parents’ smoking status, masculinity and curiosity. The results indicated that adolescents consider smoking as a social habit but with contradictory feelings. The smoking habit was also stimulated by peer pressure, imitating parents who smoke, feeling masculine and curiosity.

Conclusion

We suggest that health professionals who are interested in developing smoking prevention programs in Indonesia should consider the adolescent perspective on smoking so that the prevention program will be more effective and appropriate for adolescents.

The Natural Course of Cigarette Smoking among Adolescent Daily Smokers in France and Quebec

Objective:

To describe the natural course of cigarette smoking and nicotine dependence (ND) over 1-year in daily smokers ages 15 to 17 living in different social contexts.

Method:

Cigarette smoking and ND indicators were measured at baseline and 3- and 12-months thereafter among 95 daily smokers with a total of 123 observations from the Nicotine Dependence in Teens (NDIT) Study in Quebec, Canada, and in 111 daily smokers from the TABagisme chez les ADOlescents (TABADO) Study in Lorraine, France.

Results:

NDIT and TABADO participants initiated smoking a mean (SD) of 3.9 (1.6) and 3.7 (2.0) years prior to baseline, respectively. Despite baseline differences in age, sex, age at initiation, number of cigarettes smoked per day and social context, 85% of participants in both samples reported cravings and responded “yes” to “felt like you really need a cigarette”. Mean (SD) number of cigarettes smoked per day increased from 9.4 (8.1) to 11.8 (8.0) over 1 year in NDIT (adjusted mean difference (95% CI) = 2.4 (0.8, 3.0)), and from 11.5 (6.5) to 13.5 (6.7) in TABADO (adjusted mean difference (95% CI) = 2.0 (0.8, 3.1)). However, most ND indicators in both samples were stable over time and cessation was infrequent.

Conclusion:

Despite notable differences across samples, the natural course of cigarettes smoked per day, ND symptoms and cessation was similar, suggestive of an underlying biologic rather than social process. To quit, adolescents who smoke daily will likely need (pharmacologic) intervention to counter the biological mechanisms underpinning ND, as well as complementary strategies targeting the social context such as creating social environments favoring cessation success.

Stigma and Smoking in the Home: Parents' Accounts of Using Nicotine Replacement Therapy to Protect Their Children from Second-Hand Smoke

Evidence and campaigns highlighting smoking and second-hand smoke risks have significantly reduced smoking prevalence and denormalised smoking in the home in Scotland. However, smoking prevalence remains disproportionally high in socioeconomically disadvantaged groups. Using stigma as a theoretical lens, this article presents a thematic analysis of parents' accounts of attempting to abstain from smoking at home, using nicotine replacement therapy (NRT), in disadvantaged areas of Edinburgh and the Lothians. Smoking stigma, particularly self-stigma, underpinned accounts, with two overarching themes: interplaying barriers and enablers for creation of a smoke-free home and reconceptualisation of the study as an opportunity to quit smoking. Personal motivation to abstain or stop smoking empowered participants to reduce or quit smoking to resist stigma. For those struggling to believe in their ability to stop smoking, stigma led to negative self-labelling. Previously hidden smoking in the home gradually emerged in accounts, suggesting that parents may fear disclosure of smoking in the home in societies where smoking stigma exists. This study suggests that stigma may act both as an enabler and barrier in this group. Reductions in smoking in the home were dependent on self-efficacy and motivations to abstain, and stigma was entwined in these beliefs.

Estimating and mapping cigarette butt littering in urban environments: A GIS approach

BACKGROUND

Cigarette butts are some of the most common form of litter in the World, causing severe environmental damage. Analysing spatial distribution of cigarette butts in the urban environment may lead to useful insights for further interventions to reduce this form of litter. In this study, we present a GIS-based methodology to estimate the density of cigarette butts across a large urban area.

METHODS

We collected information about discarded cigarette butts in outdoor public spaces by systematic social observation in a diverse sample of areas in Madrid, Spain. We used these data to estimate the density of cigarette butts in public spaces around the entire city by performing GIS analyses based on Kernel Density Estimations. Last, we validated these measures using on-field observations in a set of locations across the city.

RESULTS

Hospitality venues and public transportation stops were the places with the highest concentrations of cigarette butts, followed by the entrances to educational venues and playgrounds. Central districts showed the highest amount of cigarette butts in contrast to peripheral ones. We found that our measure had good validity, with a correlation coefficient of 0.784.

DISCUSSION

This is the first study estimating and mapping cigarette butt litter in a large urban area. We identified a set of outdoor public places with high concentrations of cigarette butts and found geographical unevenness in the distribution of this pervasive form of litter across the study area. Our findings demonstrate the ubiquitous nature of cigarette butts in the urban environment and the need for interventions to reduce its impact on both people's health and the environment.

Factors Affecting Smoking Initiation and Cessation Among Saudi Women Attending Smoking Cessation Clinics

Objectives

Smoking is one of the most adaptable risk behaviours associated with increased mortality rates, yet over one billion individuals worldwide are smokers. This study aimed to examine self-reported reasons for starting and quitting smoking among women attending smoking cessation clinics in Saudi Arabia.

Methods

This cross-sectional study took place between January 2014 and January 2017 in Saudi Arabia using previously collected data. A survey was distributed to 3,000 female smokers attending smoking cessation programmes in 18 clinics from different regions in Saudi Arabia to determine self-reported reasons for smoking initiation and willingness/unwillingness to quit.

Results

A total of 2,190 women participated in the study (response rate = 73%). Overall, the most common reason for starting to smoke was friends (31.1%), while the predominant reason for willingness to quit was health concerns (45.5%). The most frequent reason for being unwilling to quit smoking was a fear of mood changes (28%).

Conclusion

Most Saudi women are socially-driven to start smoking, while the most common reason for quitting is health concerns. The latter finding is promising in that it shows that smokers are gaining awareness of the adverse effects of smoking.

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.

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.

Tobacco use in the sexual borderlands: The smoking contexts and practices of bisexual young adults

Little is known about why bisexual people use tobacco at higher rates than any other sexual identity group. Non-binary sexualities, such as bisexuality, exist within the socially constructed borderland between homosexuality and heterosexuality. Exploration of the everyday smoking contexts and practices of bisexual individuals may reveal unique mechanisms driving tobacco use. We employed a novel mixed method, integrating real-time, smartphone-administered surveys of (non)smoking situations, location tracking, spatial visualization of participant data, and subsequent map-led interviews. Participants (n = 17; ages 18-26, California) identified as bisexual, pansexual, and/or queer. Most were cisgender women. Survey smoking patterns and situational predictors were similar to other young adults'. However, interviews revealed unique roles of tobacco use in participants' navigation of differently sexualized spaces in everyday life: 1) stepping away from uncomfortable situations related to bisexual identity; 2) facilitating belonging to LGBTQ+ community; and 3) recovering from bisexual identity perception management. Similar studies can examine the place-embedded practices and spatio-temporal patterns of other substance use and other stigmatized identity experiences.

"Don't smoke in public, you look like trash": An exploratory study about women's experiences of smoking-related stigmatisation and the connection to neighbourhood-level deprivation

In this exploratory qualitative study we used Goffman's theory of stigmatisation to examine how women experience smoking-related stigma in relation to neighbourhood-level deprivation. From an existing cohort, we recruited fifteen women who smoked. We found differences in the women's experiences and abilities to negotiate and avoid a stigmatised smoking identity based on neighbourhood-level deprivation. Women in high-deprivation neighbourhoods described limited access to such places and this restricted their abilities to 'pass' as non- or not-quite-smokers and avoid smoking-related stigmatisation. We discuss the implications of the findings in relation to social-spatial inequalities in health and public health policy.

"It's a hard thing to manage when you're homeless": the impact of the social environment on smoking cessation for smokers experiencing homelessness

BACKGROUND

Up to 80% of the adult homeless population use tobacco, and smoking cessation programs could offer an important opportunity to address preventable mortality and morbidity for this population. This population faces serious challenges to smoking cessation, including the impact of the social environment.

METHODS

Forty participants (11 female; 29 male) from an ongoing smoking cessation randomized clinical trial conducted at 2 urban homeless shelters in the Upper Midwest were invited to take part in semi-structured interviews in 2016-2017. An interviewer used a semi-structured interview guide asking participants to describe their experience of how the social environment impacted their attempt to quit smoking.

RESULTS

Participants described feeling pressure to smoke and drink in and around shelters, and that this pressure had led some to start smoking or resume smoking, along with making it very challenging to quit. Participants described being motivated to quit, and seeing smoking cessation as positively impacting the time and focus they felt they had for finding housing. However many felt more interested in reducing their smoking, rather than quitting.

CONCLUSIONS

Addressing smoking cessation for people experiencing homelessness is both an important public health opportunity, and a challenge. There is a need to consider cessation in the context of the social and environmental factors impacting smokers who are experiencing homelessness. In particular, there is a need to address the collective value placed on smoking in social interactions. Despite these challenges, there are high levels of motivation and interest in addressing smoking.

TRIAL REGISTRATION

NCT01932996 . Date of registration 30th August 2013. Prospectively registered.

Moving Beyond the Behavior-Change Framework for Smoking Cessation: Lessons for a Critical Ontology From the Case of Inpatient Psychiatric Units

BACKGROUND: Leading scholars have called on nursing schools to pay more attention to smoking cessation in the education of nursing students. AIM: This article argues that attention to this subject should include a rethinking of the behavior-change framework that forms the methodological basis of this field. METHOD: Drawing on classic and contemporary work in sociology, anthropology, and critical public health, this article explores the specific example of smoking in long-term inpatient units to illustrate the limitations of a behavior-based ontology and suggest an alternative conceptual vocabulary. RESULTS: An alternative approach posits smoking as a social practice. It sheds light on situational factors that incentivize smoking and might be contributing to patient resistance to cessation. CONCLUSIONS: A different conceptual framing of smoking can point to interventions beyond the level of individuals, focusing instead on the broader interface between people and situations, where decisions and desires meet institutional and organizational dynamics and structures of opportunity and access.

The "here and now" of youth: the meanings of smoking for sexual and gender minority youth

BACKGROUND

The mainstream tobacco field in the USA tends to situate youth as passive, particularly in terms of their susceptibility to industry manipulation and peer pressure. However, failing to acknowledge youths' agency overlooks important meanings youth ascribe to their tobacco use and how those meanings are shaped by the circumstances and structures of their everyday lives.

METHODS

This article is based on analysis of 58 in-depth qualitative interviews conducted with sexual and gender minority youth living in the San Francisco Bay area in California. Topics covered in interviews focused on meanings of tobacco in the lives of youth. Interviews lasted approximately 2.5 h and were transcribed verbatim and linked with ATLAS.ti, a qualitative data analysis software. Following qualitative coding, narrative segments were sorted into piles of similarity identified according to principles of pattern-level analysis to interpret to what extent meanings of smoking for young people may operate as forms of resistance, survival, and defense.

RESULTS

Analysis of our participants' narratives highlights how smoking is connected to what Bucholtz calls the "'here-and-now' of young people's experience, the social and cultural practices through which they shape their worlds" as active agents (Bucholtz, Annu Rev Anthropol31:525-52, 2003.). Specifically, narratives illustrate how smoking signifies "control" in a multitude of ways, including taking control over an oppressor, controlling the effects of exposure to traumatic or day-to-day stress, and exerting control over the physical body in terms of protecting oneself from violence or defending one's mental health.

CONCLUSIONS

These findings call into question the universal appropriateness of foundational elements that underlie tobacco control and prevention efforts directed at youth in the USA, specifically the focus on abstinence and future orientation. Implications of these findings for research, prevention, and policy are discussed, emphasizing the risk of furthering health inequities should we fail to acknowledge the "here and now" of youth.

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

This paper uses the work of Bourdieu to theorise smoking and cessation through a class lens, showing that the struggle for distinction created the social gradient in smoking, with smoking stigma operating as a proxy for class stigma. This led to increased policy focus on the health of bystanders and children and later also to concerns about electronic cigarettes. Bourdieu's concept of habitus is deployed to argue that the e-cigarette helps middle-class smokers resolve smoking as a symptom of cleft habitus associated with social mobility or particular subcultures. E-cigarette use is also compatible with family responsibility and sociable hedonism; aspects of working-class habitus which map to the 'practical family quitter' and the 'recreational user' respectively. The effectiveness of class stigma in changing health behaviours is contested, as is the usefulness of youth as a category of analysis and hence the relevance of concerns about young people's e-cigarette use outside a class framework of smoking and cessation. With regard to health inequalities, whilst middle-class smokers have in class disgust a stronger incentive to quit than working-class smokers, there is potential for tobacco control to tap into a working-class ethos of family care and responsibility.

A geographically explicit ecological momentary assessment (GEMA) mixed method for understanding substance use

Tobacco use is increasingly concentrated within marginalized groups, including LGBTQ+ young adults. Developing tailored interventions to reduce tobacco-related health disparities requires understanding the mechanisms linking individual and contextual factors associated with tobacco use to behavior. This paper presents an in-depth exploration of three cases from a novel mixed method study designed to identify the situational factors and place-based practices of substance use among high-risk individuals. We combined geographically explicit ecological momentary assessment (GEMA) with an adapted travel diary-interview method. Participants (young adult bisexual smokers, ages 18-26) reported on non-smoking and smoking situations for 30 days with a smartphone app. GEMA surveys captured internal and external situational factors (e.g., craving intensity, location type, seeing others smoking). Continuous locational data was collected via smartphone GPS. Subsequently, participants completed in-depth interviews reviewing maps of their own GEMA data. GEMA data and transcripts were analyzed separately and integrated at the case level in a matrix. Using GEMA maps to guide the interview grounded discussion in participants' everyday smoking situations and routines. Interviews clarified participant interpretation of GEMA measures and revealed experiences and meanings of smoking locations and practices. The GEMA method identified the most frequent smoking locations/times for each participant (e.g., afternoons at university). Interviews provided description of associated situational factors and perceptions of smoking contexts (e.g., peer rejection of bisexual identity) and the roles of smoking therein (e.g., physically escape uncomfortable environments). In conclusion, this mixed method contributes to advancing qualitative GIS and other hypothesis-generating approaches working to reveal the richness of individuals' experiences of the everyday contexts of health behavior, while also providing reliable measures of situational predictors of behaviors of interest, such as substance use. Limitations of and future directions for the method are discussed.