Becoming a 'real' smoker: cultural capital in young women's accounts of smoking and other substance use

Perceptions of friendship, peers and influence on adolescent smoking according to tobacco control context: a systematic review and meta-ethnography of qualitative research

BACKGROUND

A relationship between smoking and interpersonal influences has been well established within the literature. There have been cultural shifts in denormalisation and a reduction in tobacco smoking in many countries. Hence there is a need to understand social influences on adolescents' smoking across smoking normalisation contexts.

METHODS

The search was conducted in July 2019 and updated in March 2022 within 11 databases and secondary sources. Search terms included schools, adolescents, smoking, peers, social norms and qualitative research. Screening was conducted by two researchers independently and in duplicate. Study quality was assessed using the eight-item Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-centre) tool for the appraisal of qualitative studies. Results were synthesised using a meta-narrative lens for meta-ethnography and compared across smoking normalisation contexts.

RESULTS

Forty one studies were included and five themes were developed, mapping onto the socio ecological model. The social processes by which adolescents take up smoking differed according to a mixture of school type, peer group structure and the smoking culture within the school, as well as the wider cultural context. Data available from smoking denormalised contexts, described changes in social interactions around smoking to cope with its stigmatisation. This was manifested through i) direct peer influence, whereby subtle techniques were employed, ii) group belonging whereby smoking was less likely to be seen as a key determinant of group membership and smoking was less commonly reported to be used as a social tool, and iii) popularity and identity construction, whereby smoking was perceived more negatively in a denormalised context, compared with a normalised context.

CONCLUSIONS

This meta-ethnography is the first study to demonstrate, drawing on international data, that peer processes in adolescent smoking may undergo changes as smoking norms within society change. Future research should focus on understanding differences across socioeconomic contexts, to inform the adaptation of interventions.

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.

"You Do It Through the Grapevine": A Bourdieusian Analysis of Under-Age Access to Tobacco Among Adolescents From Seven European Cities

Despite efforts to reduce adolescent smoking via minimum age-of-sale legislation, many young people continue to access tobacco through a mix of social and commercial sources. Little is known about the roles of habitus, capital, and social topographies in shaping under-age access to tobacco. This article draws on Bourdieu's theory of practice and data generated from 56 focus groups with 14- to 19-year-olds across seven European cities to answer the question "via what sources and by what means do adolescents obtain tobacco?" We find that adolescents use a range of personal capitals (social, cultural, and economic) to access tobacco, with the specific constitution and deployment of these capitals varying according to the regularities of different fields. Since adolescents access tobacco via culturally embedded practices, attempts to curtail this access are more likely to be effective if they are multi-pronged, culturally informed, and attuned to the lived experiences of adolescent smokers.

The emerging norms of e-cigarette use among adolescents: A meta-ethnography of qualitative evidence

While qualitative research has indicated that adolescents' motivation for e-cigarette use is different than adults', this body of literature has not yet been brought together and synthesised. We reviewed qualitative evidence on perceptions and uses of e-cigarettes in order to explore the emerging norms of vaping among adolescents. We searched five databases for qualitative research in October 2019 with no restrictions on date of publication or data collection. We identified fifteen papers from thirteen studies. Using a meta-ethnographic approach, we identified a spectrum of descriptive and injunctive norms of vaping across the themes of addiction; perceptions of comparative harm; parental perceptions and peer perceptions. We found addiction and perceptions of comparative harm to reflect descriptive norms, while we found clearer evidence explaining the use and non-use of e-cigarettes through parental and peer approval of vaping. However, these norms were fluid, diverse and sometimes contradictory. This review provides a resource for researchers, policymakers and practitioners to better understand the ways that emerging norms could be influenced through policy and practice.

Places to Smoke: Exploring Smoking-Related Practices among Danish Adolescents

Several established school smoking prevention initiatives involve restrictions on places to smoke. The focus on tobacco control in schools is due to the risk of smoking initiation during adolescence and the perception of this life stage as a period of time when health behavior is established. Hence, this period of time is considered to be ideal for health-promoting initiatives. This paper is part of an ethnographic study on adolescents' perceptions of tobacco use. Focus groups and field observations were used to explore adolescents' smoking-related practices related to smoking bans at schools. The findings show that smoking, as a place-based practice, is influenced by locally embedded rules and carries social implications resulting in a distinction between smokers and non-smokers. The distinction between smokers and non-smokers contributes to the retention of a stereotypical view of smokers and, moreover, stigmatizes smokers. According to this, restrictions on places to smoke within the school should be considered carefully in order to avoid stigma or ethical issues.

To smoke or not to smoke? A qualitative study among young adults

Smoking is the major preventable cause of disease and premature death in many countries, including France, where approximately 30% of adults are daily smokers. About 60% of them want to quit, however, long-term smoking cessation rates are low, particularly among individuals with low socio-economic position. The aim of this study is to examine whether motivations for smoking cessation among young adults differ across socio-economic groups.

3 focus groups of smokers and former smokers aged 22–40 years were constituted and conducted in November 2014 in Paris. Data from the focus groups were analyzed thematically and in a cross-cutting manner. Our study shows the existence of social “communities” of smokers, in occupational and festive contexts. In addition, new forms of resistance to public health messages are observed (“neutralization”), particularly among smokers with low socioeconomic position. Finally, stress is often cited as a source of unsuccessful smoking cessation or smoking relapse. Tobacco smoking is a social behavior and is associated with symbolic as well as relational benefits, particularly among smokers who have low socioeconomic position. To be effective, interventions aiming to decrease smoking levels in the population should aim to create group dynamics encouraging smokers to quit and address the physical as well as the psychological consequences of smoking withdrawal.

•

Young adults who smoke congregate in social “communities”, at work or at parties.

•

Persons with low socioeconomic status “neutralize” the risks related to smoking.

•

Smoking is a social behavior, associated with symbolic and relational benefits.

"They're thinking, well it's not as bad, I probably won't get addicted to that. But it's still got the nicotine in it, so…": Maturity, Control, and Socializing: Negotiating Identities in Relation to Smoking and Vaping-A Qualitative Study of Young Adults in Scotland

Objective

To explore the understandings of and engagement with e-cigarettes, of young adults from disadvantaged backgrounds, and how these may have an impact on existing smoking identities.

Methods

Twenty-two small group and 11 individual qualitative interviews were conducted in Central Scotland with 72 16-24 year olds between September 2015 and April 2016. Participants were mostly smokers and ex-smokers from socioeconomically disadvantaged backgrounds.

Results

Although most participants had tried e-cigarettes, they generally held ambivalent views about e-cigarettes and vaping. Two overarching themes were identified which helped in understanding this. Firstly, e-cigarettes were understood by the participants in relation to their existing smoking identities. Vaping was viewed as less controllable and more addictive than smoking, which did not fit with their self-identity as controlled smokers. Secondly, they felt that vaping could not replace the social and cultural importance that smoking had in their lives.

Conclusion

This study suggests that though young adults from disadvantaged areas are trying e-cigarettes for various reasons, vaping is rarely sustained. Through their own experiences of vaping and their observations of others vaping, the participants perceive the behavior as endangering an existing acceptable and controlled smoking identity. Additionally, e-cigarettes were considered to be a jarring presence in existing social situations where smoking was valued. This study, therefore, provides insights into how young adults may be rationalizing their continued smoking in the face of potentially less harmful alternatives.

Implications

As new and novel nicotine delivery devices, and due to their similarity to smoking, e-cigarettes have the potential to help smokers in their quit attempts. However, the findings from this study raise questions about whether e-cigarettes are regarded as having this potential by young adult smokers from disadvantaged socioeconomic environments where smoking is more commonplace and acceptable.

"Tell them you smoke, you'll get more breaks": a qualitative study of occupational and social contexts of young adult smoking in Scotland

OBJECTIVE

To explore young adults' perceptions and experiences of smoking and their smoking trajectories in the context of their social and occupational histories and transitions, in a country with advanced tobacco control.

DESIGN

Indepth qualitative interviews using day and life grids to explore participants' smoking behaviour and trajectories in relation to their educational, occupational and social histories and transitions.

SETTING

Scotland.

PARTICIPANTS

Fifteen ever-smokers aged 20-24 years old in 2016-2017.

RESULTS

Participants had varied and complex educational/employment histories. Becoming and/or remaining a smoker was often related to social context and educational/occupational transitions. In several contexts smoking and becoming a smoker had perceived benefits. These included getting work breaks and dealing with stress and boredom, which were common in the low-paid, unskilled jobs undertaken by participants. In some social contexts smoking was used as a marker of time out and sociability.

CONCLUSIONS

The findings indicate that while increased tobacco control, including smokefree policies, and social disapproval of smoking discourage smoking uptake and increase motivations to quit among young adults, in some social and occupational contexts smoking still has perceived benefits. This finding helps explain why smoking uptake continues into the mid-20s. It also highlights the importance of policies that reduce the perceived desirability of smoking and that create more positive working environments for young adults which address the types of working hours and conditions that may encourage smoking.

[Socioeconomic profile and smoking among adolescents in vocational training]

BACKGROUND

Targeted interventions among vulnerable youth populations represent an important approach to the reduction of health inequalities. We must, however, ensure that impacts are not unequally distributed according to the range of resources available to them. We explore these concerns among youth in vocational training to be enrolled in a smoking cessation intervention by describing (1) their socio-economic profile and (2) the association between their socioeconomic characteristics, their smoking practices, and key factors that could be targeted in interventions.

METHODS

A total of 234 young people aged 15-20 years were recruited in three centers in the Lorraine region in France in 2016-2017 as part of the Social Network and Tobacco Cessation (Réseau social et sevrage tabagique [RESIST]) study. We measured participants' socio-economic characteristics using their parents' education and occupational grade. We examined the associations of these characteristics with participants' smoking habits, intention to quit, nicotine dependence, presence of smokers in their network, and representation of a young smoker. We examined the associations between variables with bivariate tests depending on the nature of the variables.

RESULTS

Participants were more likely to be from a socio-professional background more modest than the national average (56% versus 33%), but still exhibited considerable socioeconomic variability. Smoking status did not vary significantly according to the educational level of the participants' parents (from 52% to 57%, P=0.78) or occupational grade (from 52% to 58%, P=0.35). Compared to participants whose parents had completed a professional or pre-university degree, participants with parents in the lowest education category were less likely to report not intending to quit (P=0.01) and more likely to report seriously considering to quit in the next six months (P=0.03) and to have already tried to quit but failed (P=0.01).

CONCLUSION

It is tempting to define youth in vocational training as a homogeneous group, especially when they share the same school environment, employment status, and income. Our results, however, highlight substantial variability in their socioeconomic profiles and smoking characteristics. Researchers are encouraged to further consider these equity issues to contribute to the reduction of health inequalities.

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.

Today's decisions, Tomorrow's outcomes: Does self-control explain the educational smoking gradient?

People with more education tend to have relatively healthy lifestyles. Among other things, they smoke less than those with less education. This link between education and smoking (known as the "educational gradient") is frequently interpreted as causal: many researchers argue that education develops skills, habits, and preferences that discourage smoking and other unhealthy behaviors. However, an alternative possibility is that these skills, habits, and preferences develop early in life and determine the likelihood of both attaining a high level of education and avoiding smoking. I test the latter possibility using data from the Longitudinal Study of Adolescent to Adult Health (Add Health). In particular, I assess the degree to which indicators of self-control in adolescence explain the association between educational attainment and smoking in adulthood. Results from a series of regression-based tests indicate that self-control is a significant predictor of both outcomes, even when controlling for a host of other risk factors. However, it does not appear to explain the educational gradient.

Gender matters in cardiac rehabilitation and diabetes: Using Bourdieu's concepts

BACKGROUND

Habitual practices are challenged by chronic illness. Cardiac rehabilitation (CR) involves changes to habits of diet, activity and tobacco use, and although it is effective for people with diabetes and cardiovascular disease (CVD), some participants are reportedly less likely to complete programs and adopt new health related practices. Within the first three months of enrolling in CR, attrition rates are highest for women and for people with diabetes. Previous studies and reviews indicate that altering habits is very difficult, and the social significance of such change requires further study.

PURPOSE

The purpose of the study was to use Bourdieu's concepts of habitus, capital and field to analyse the complexities of adopting new health practices within the first three months after enrolling in a CR program. We were particularly interested in gender issues.

METHODS

Thirty-two men and women with diabetes and CVD were each interviewed twice within the first three months of their enrolment in one of three CR programs in Toronto, Canada.

RESULTS

Attention to CR goals was not always the primary consideration for study participants. Instead, a central concern was to restore social dignity within other fields of activity, including family, friendships, and employment. Thus, study participants evolved improvised tactical approaches that combined both physical and social rehabilitation. These improvised tactics were socially embedded and blended new cultural capital with existing (often gendered) cultural capital and included: concealment, mobilizing cooperation, re-positioning, and push-back.

CONCLUSIONS

Our findings suggest that success in CR requires certain baseline levels of capital - including embodied, often gendered, cultural capital - and that efforts to follow CR recommendations may alter social positioning.

An Intersectional Analysis of Women's Experiences of Smoking-Related Stigma

In this article, we explore how young women encounter and counter discourses of smoking-related stigma. Twenty-seven young Australian women, smokers and ex-smokers, took part in interviews. A sub-sample of 18 participants took photographs to document their smoking experience, and took part in a second interview. Data were analyzed through Foucauldian discourse analysis. Four discourses were identified: "smoking as stigmatized," "the smoking double standard," "smoking as lower class," and "smokers as bad mothers." The women negotiated stigma in a variety of ways, shifting between agreeing, disagreeing, challenging, and displacing stigma onto "other" smokers. These experiences and negotiations of smoking-related stigma were shaped by intersecting identities, including gender, cultural background, social class, and mothering, which at times, compounded levels of stigmatization. It is concluded that tobacco control measures should consider the negative implications of smoking-related stigma, and the potential for women to experience compounding levels of stigma.

Doing and undoing femininities: An intersectional analysis of young women’s smoking

Previous research has found that young women’s smoking relates to their performance of feminine gender identities. Using an intersectional approach, we explore in this study how young women’s smoking is implicated in the doing and undoing of femininities, as well as other intersecting identities. Discourse analysis was used to examine interviews and a photography activity conducted with young women, both current and ex-smokers. This analysis revealed four culturally dominant repertoires: “cigarettes and smoking styles as gendered”, “smoking as controlling weight”, “smoking as a sexual tool”, and “smoking as compromising appearance”. Young women’s experiences and negotiations of discourse surrounding smoking and femininity were shaped by intersecting social class and sexual identities. These findings can be used to inform the development of smoking cessation interventions which recognise the diversity in how young women perform femininity.

The Gendered Experience of Smoking Stigma: Implications for Tobacco Control

Tobacco denormalization is a widely accepted tobacco control strategy, shaping policies and programs throughout the United States as well as globally. In spite of widespread beliefs about the effectiveness of tobacco denormalization approaches, concerns about their emphasis on stigmatization have emerged. Social science research on smoking stigma raises questions about the potential iatrogenic consequences of tobacco denormalization approaches. Few studies have considered how smoking stigma may be internalized differently by different people, particularly those who experience stigmatization because of other socially-ascribed makers of inequity (e.g. race, ethnicity, gender, sexuality). The intersection of multiple stigmas may work to intensify the "social isolation and marginalization" that some people already experience (Greaves & Hemsing 2009; pg S127). This paper presents results from a pattern-level analysis of focus group and interview data from a study investigating smoking-related stigma and perceptions of tobacco denormalization approaches among 15 low income Black women who smoke in the San Francisco Bay Area. Our analysis revealed a cycle where Black women's experiences with structural oppression resulted in stress and the use of cigarettes to cope with that stress. Though the connection between smoking and stress is well documented in previous research, our analysis further revealed the additional contribution of the stigmatization of smoking and how it intensifies inequity for Black women who smoke. Implications of these findings for tobacco control and prevention are discussed.

Sex Differences in Hookah-Related Images Posted on Tumblr: A Content Analysis

Hookah tobacco smoking is prevalent, widespread, and associated with large amounts of toxicants. Hookah tobacco smoking may be viewed differently by males and females. For example, females have been drawn to types of tobacco that are flavored, milder, and marketed as more social and exotic. Individuals often use the growing segment of anonymous social networking sites, such as Tumblr, to learn about potentially dangerous or harmful behaviors. We used a systematic process involving stratification by time of day, day of week, and search term to gather a sample of 140 Tumblr posts related to hookah tobacco smoking. After a structured codebook development process, 2 coders independently assessed all posts in their entirety, and all disagreements were easily adjudicated. When data on poster sex and age were available, we found that 77% of posts were posted by females and 35% were posted by individuals younger than 18. The most prominent features displayed in all posts were references to or images of hookahs themselves, sexuality, socializing, alcohol, hookah smoke, and tricks performed with hookah smoke. Compared with females, males more frequently posted images of hookahs and alcohol-related images or references. This information may help guide future research in this area and the development of targeted interventions to curb this behavior.

Adolescent (Mis)Perceptions About Nicotine Addiction: Results From a Mixed-Methods Study

PURPOSE

Despite evidence that adolescents become addicted to nicotine even after limited use, adolescents believe they can experiment with or smoke cigarettes for a few years and easily quit. The goal of this study was to examine adolescents' understanding of the definition and process of nicotine addiction using a mixed-methods approach.Method A total of 367 adolescents with and without smoking experience rated the perceived risk for addiction, still being a smoker in 5 years, and ability to quit smoking. A subsample of adolescents (N= 41) were interviewed about their conceptualization and understanding of nicotine addiction. Within-participants analyses of variance were conducted to assess differences in perceptions of addiction across the three scenarios; thematic analyses of interviews were conducted to assess adolescents' understanding of addiction.Results Adolescents rated their perceived risk for addiction, still being a smoker in 5 years, and ability to quit as significantly different from one another for three different scenarios (F= 7.81, 47.78, and 70.27, respectively;p< .001). Seven themes describing how youth conceptualize and understand addiction emerged from the interview data, including skepticism and uncertainty about addiction, how smoking makes a person feel, and family and friends' experiences.

CONCLUSION

While adolescents have received the message that cigarettes are addictive, they are uncertain regarding the definition of addiction and have not recognized that addiction means experiencing difficulty quitting and continuing to smoke longer than expected. Findings suggest the need for comprehensive messaging regarding nicotine addiction in educational, clinical, and intervention settings and for product warning messages aimed at reducing and preventing tobacco use.

Existential multiplicity and the late-modern smoker: negotiating multiple identities in a support group for smoking cessation

To examine identity work of smokers attempting to quit, we undertook participant observation at an Israeli cessation support group. Grounded theory and thematic analysis of group dialogue permitted identification of recurring themes and the presentation of illustrative vignettes. We found that, rather than the linear, goal-oriented constitution of a univocal non-smoking identity, identity work entailed re-appraisals of the experience of liminality between smoking and non-smoking selves. Although the group participants reduced their tobacco consumption and some even quit, specific technologies of self sustained the smoking self alongside the non-smoking self. We propose that the social contextualisation of the smoker in the context of late modernity may explain the tolerance of chronic ambivalence and the constitution of a 'resistant' smoking- non-smoking self. Phenomenological accounts of the experience of this hybrid self may more fully explain protracted or failed cessation and further deconstruct binary readings of indulgence or control, addiction or abstinence and illness or wellness. Our findings call for the re-conceptualisation of the experience and outcome of protracted cessation and a tolerant policy-driven intervention.

'What a man can do, a woman can do better': gendered alcohol consumption and (de)construction of social identity among young Nigerians

BACKGROUND

The misuse of alcohol and other drugs among young people, especially students, is a growing global phenomenon. In traditional Nigerian society, different locally-produced alcoholic beverages served complex roles but were mainly consumed among adult males for pleasure. Though adult females in some communities consumed alcohol, the practice of drinking was culturally controlled. In contemporary Nigeria, available quantitative studies reveal changing patterns of alcohol use amongst youth but fail to unravel the social variables that motivate alcohol use among this group.

METHODS

Qualitative data were collected through in-depth interviews with 31 (22 males and 9 females, aged 19-23 years) undergraduate students attending a university located in a metropolitan city in Anambra State, south-eastern Nigeria. Data were collected and analysed to generate themes with the aid of Nvivo 10 software.

RESULTS

There appears to be a resilient socio-cultural belief in which men see alcohol as 'good for males' while the females in contrast believe that alcohol does not discriminate according to gender and should be drunk by both males and females. Findings also point to the ways in which male-gendered drinking behaviours, such as heavy or fast drinking are employed by women to develop social capital.

CONCLUSIONS

These results do suggest how gendered constructions of alcohol consumption create risks for both men and women, how they negotiate and ameliorate those risks, and how women challenge gender roles through their use of alcohol. Some focus on formulating evidence-based policies and comprehensively evaluated campaigns are needed to disseminate information about the risks and potential consequences of heavy alcohol consumption in order to promote safer alcohol use by young people.

A qualitative content analysis of cigarette health warning labels in Australia, Canada, the United Kingdom, and the United States

The legislation of health warning labels on cigarette packaging is a major focus for tobacco control internationally and is a key component of the World Health Organization's Framework Convention on Tobacco Control. This population-level intervention is broadly supported as a vital measure for warning people about the health consequences of smoking. However, some components of this approach warrant close critical inspection. Through a qualitative content analysis of the imagery used on health warning labels from 4 countries, we consider how this imagery depicts people that smoke. By critically analyzing this aspect of the visual culture of tobacco control, we argue that this imagery has the potential for unintended consequences, and obscures the social and embodied contexts in which smoking is experienced.

Gender, smoking and tobacco reduction and cessation: a scoping review

Considerations of how gender-related factors influence smoking first appeared over 20 years ago in the work of critical and feminist scholars. This scholarship highlighted the need to consider the social and cultural context of women's tobacco use and the relationships between smoking and gender inequity. Parallel research on men's smoking and masculinities has only recently emerged with some attention being given to gender influences on men's tobacco use. Since that time, a multidisciplinary literature addressing women and men's tobacco use has spanned the social, psychological and medical sciences. To incorporate these gender-related factors into tobacco reduction and cessation interventions, our research team identified the need to clarify the current theoretical and methodological interpretations of gender within the context of tobacco research. To address this need a scoping review of the published literature was conducted focussing on tobacco reduction and cessation from the perspective of three aspects of gender: gender roles, gender identities, and gender relations. Findings of the review indicate that there is a need for greater clarity on how researchers define and conceptualize gender and its significance for tobacco control. Patterns and anomalies in the literature are described to guide the future development of interventions that are gender-sensitive and gender-specific. Three principles for including gender-related factors in tobacco reduction and cessation interventions were identified: a) the need to build upon solid conceptualizations of gender, b) the importance of including components that comprehensively address gender-related influences, and c) the importance of promoting gender equity and healthy gender norms, roles and relations.

A relational approach to health practices: towards transcending the agency-structure divide

Many health scholars find that Pierre Bourdieu's theory of practice leaves too little room for individual agency. We contend that, by virtue of its relational, field-theoretic underpinnings, the idea of leaving room for agency in Bourdieu's theory of practice is misguided. With agency manifested in interactions and social structures consisting of relations built upon relations, the stark distinction between agency and structure inherent to substantialist thinking is undermined, even dissolved, in a relational field-theoretic context. We also contend that, when treated as relationally bound phenomena, Bourdieu's notions of habitus, doxa, capital and field illuminate creative, adaptive and future-looking practices. We conclude by discussing difficulties inherent to implementing a relational theory of practice in health promotion and public health.

A qualitative study of how young Scottish smokers living in disadvantaged communities get their cigarettes

INTRODUCTION

Reducing access to cigarettes is an important element of youth smoking prevention strategies. This is particularly so in disadvantaged communities that have high rates of youth smoking. In 2010, Scotland banned proxy sales of tobacco products to under 18-year-olds who were getting older people to purchase cigarettes on their behalf.

METHODS

A qualitative study using 24 small single-sex friendship groups. Eighty young people, mostly aged 14-16, of whom 57 were smokers, were recruited in 2012 from community youth groups in 3 socially disadvantaged areas of Scotland.

RESULTS

Participants' main sources of cigarettes were proxy sales, family, and peers and friends. Younger smokers were more likely to purchase single cigarettes from older smokers at school and to steal cigarettes from family members. Older and regular smokers were more likely to obtain cigarettes through proxy purchases. Proxy purchases were often facilitated by problem drug users who were willing to buy cigarettes for a small monetary reward. Direct purchases in shops were less commonly reported but appeared to involve complicit action by some retailers. Few reported that they bought blackmarket cigarettes, although they were available in these communities.

CONCLUSIONS

Young people in areas of deprivation are still able to circumvent the age-of-sale legislation on selling cigarettes. Even though proxy sales have been banned, they are an important source of cigarettes for disadvantaged young smokers.

Social network influences on smoking, drinking and drug use in secondary school: centrifugal and centripetal forces

We explore how school experiences and social networks structure young people's substance use in different institutional contexts. The concepts of 'selection' and 'influence' are situated within the context of bounded agency, counter-school cultures and Bourdieusian notions of capital. We employed individual and group interviews, network-mapping, and observations at two contrasting English secondary schools. Both schools were characterised by extended social network structures that appeared to influence patterns of substance use, although the mechanisms via which this occurred varied according to school context. At Grange House school (suburban context) a minority of students from disadvantaged families were alienated by the attainment-focused regime, marginalised by a strong peer-led centrifugal force pushing them outwards, and substance use was an alternative source of bonding and identity for these students. In contrast, at North Street a centripetal force operated whereby the majority of students were pulled towards highly-visible, normative markers of 'safe', 'road culture', such as cannabis use and gang-involvement, as they attempted to fit in and survive in an inner-city school environment. We conclude that health inequalities may be reproduced through these distinctive centrifugal and centripetal forces in different institutional contexts, and this should be the focus of quantitative examination in the UK and elsewhere.

'They don't live in my house every day': How understanding lives can aid understandings of smoking

While the prevalence of smoking in western countries has substantially reduced following the introduction of comprehensive tobacco control programs, reduction strategies such as the introduction of smokefree legislation, media campaigns and individual and group support for people trying to quit have been less successful with people living on low income, suggesting the need for new ways to engage with people who smoke. We argue that, rather than focusing solely on researching smoking behaviors to generate new understandings of why people smoke, people working in the broad area of public health should look more widely at peoples' lives in order to understand their smoking. Using a biographical, narrative perspective as part of a wider ethnographic study of 12 families living in one community within Liverpool in 2006, we argue that understandings that position smoking purely as a harmful, deviant behavior, fail to capture the cultural complexity of the lives of smokers and the changing place and meaning of cigarettes over a person's lifetime, and may explain why smokers fail to engage with smoking cessation services and continue to smoke.

Smoking spaces and practices in pubs, bars and clubs: young adults and the English smokefree legislation

Young adulthood is an important but overlooked period in the development of smoking behaviour. We know little about the impact of smokefree policies on this group. In a secondary analysis of longitudinal, qualitative interview data we explore smoking practices in young adulthood, the role of smoking in the spaces of the night-time economy, and the impact of smokefree legislation. Participants carefully managed their smoking in different spaces in relation to the self they wished to present. This was shaped by the transitional nature of young adulthood. Smoking played a role in constructing time-out periods from the demands of everyday life in a similar way to alcohol use. The restrictions imposed by the smokefree legislation quickly became normal for most; however, the experience of smoking was influenced by the nature and quality of smoking spaces. The re-spatialisation of smoking necessitated by the smokefree legislation may reaffirm processes of social denormalisation and stigmatisation of smoking, whilst simultaneously allowing young adult smokers to produce, in some contexts, a positive, fun, sociable smoker identity.

Starting to smoke: a qualitative study of the experiences of Australian indigenous youth

Background

Adult smoking has its roots in adolescence. If individuals do not initiate smoking during this period it is unlikely they ever will. In high income countries, smoking rates among Indigenous youth are disproportionately high. However, despite a wealth of literature in other populations, there is less evidence on the determinants of smoking initiation among Indigenous youth. The aim of this study was to explore the determinants of smoking among Australian Indigenous young people with a particular emphasis on the social and cultural processes that underlie tobacco use patterns among this group.

Methods

This project was undertaken in northern Australia. We undertook group interviews with 65 participants and individual in-depth interviews with 11 youth aged 13–20 years led by trained youth ‘peer researchers.’ We also used visual methods (photo-elicitation) with individual interviewees to investigate the social context in which young people do or do not smoke. Included in the sample were a smaller number of non-Indigenous youth to explore any significant differences between ethnic groups in determinants of early smoking experiences. The theory of triadic influence, an ecological model of health behaviour, was used as an organising theory for analysis.

Results

Family and peer influences play a central role in smoking uptake among Indigenous youth. Social influences to smoke are similar between Indigenous and non-Indigenous youth but are more pervasive (especially in the family domain) among Indigenous youth. While Indigenous youth report high levels of exposure to smoking role models and smoking socialisation practices among their family and social networks, this study provides some indication of a progressive denormalisation of smoking among some Indigenous youth.

Conclusions

Future initiatives aimed at preventing smoking uptake in this population need to focus on changing social normative beliefs around smoking, both at a population level and within young peoples’ immediate social environment. Such interventions could be effectively delivered in both the school and family environments. Specifically, health practitioners in contact with Indigenous families should be promoting smoke free homes and other anti-smoking socialisation behaviours.

Creating the socially marginalised youth smoker: the role of tobacco control

We discuss how the tobacco control discourse on youth smoking in Canada appears to be producing and constituting socially marginalised smokers. We analyse material from a study on social inequalities in Canadian youth smoking. Individual interviews were conducted in 2007 and 2008 with tobacco control practitioners specialising in youth smoking prevention in British Columbia and Quebec. We found that the discourse on youth smoking is creating a set of divisive practices, separating youths who have a capacity for self-control from those who do not, youths who are able to make responsible decisions from those who are not - with these distinctions often framed as a function of social class. Youths who smoke were not described simply as persons who smoke cigarettes but as individuals who, through their economic and social marginalisation, are biologically fated and behaviourally inclined to be smokers. This 'smokers' risk' discourse obscures the social structural conditions under which people smoke and reproduces the biological and behavioural reductionism of biomedicine. The collision of risk and class in the discourse on poor youth who smoke may not only be doubly burdening but may intensify social inequalities in youth smoking by forming subcultures of resistance and risk-taking.

Women's childbirth preferences and practices in the United States

Over the past two decades, research on childbirth worldwide has documented women's varied perceptions of and decision-making regarding childbirth. Scholars have demonstrated the impact of medical authority, religion, perception of risk, and access to care providers on the decisions women make about where to have their babies and with whom. Virtually all research on how women make these choices, however, has focused outside the United States. To address this gap in the literature, we analyze data collected during 2004-2010 through 135 in-depth interviews with women in the U.S. who have had hospital births, homebirths with midwives, and homebirths without professional assistance to explore the factors that led them to the births they had. We supplement these interview data with archival analysis of birth stories and ethnographic data to offer additional insight into women's birth experiences. In our analysis, we utilize Pierre Bourdieu's concepts of "habitus" and "field" to examine the ways women's preferences emerge and how a sense of risk and safety shape their decision-making around pregnancy and parturition. Our findings indicate that while women's birth preferences initially emerge from their habitus, their birth practices are ultimately shaped by broader structural forces, particularly economic position and the availability of birth options.

"It's almost expected": rural Australian Aboriginal women's reflections on smoking initiation and maintenance: a qualitative study

BACKGROUND

Despite declining smoking rates among the general Australian population, rates among Indigenous Australians remain high, with 47% of the Indigenous population reporting daily smoking - twice that of other Australians. Among women, smoking rates are highest in younger age groups, with more than half of Aboriginal women smoking during pregnancy. A lack of research focused on understanding the social context of smoking by Aboriginal women in rural Australia limits our ability to reduce these rates. This study aimed to explore the factors contributing to smoking initiation among rural Aboriginal women and girls and the social context within which smoking behaviour occurs.

METHODS

We conducted three focus groups with 14 Aboriginal women and service providers and 22 individual interviews with Aboriginal women from four rural communities to explore their perceptions of the factors contributing to smoking initiation among Aboriginal girls.

RESULTS

Four inter-related factors were considered important to understanding the social context in which girls start smoking: colonisation and the introduction of tobacco; normalization of smoking within separate Aboriginal social networks; disadvantage and stressful lives; and the importance of maintaining relationships within extended family and community networks. Within this context, young girls use smoking to attain status and as a way of asserting Aboriginal identity and group membership, a way of belonging, not of rebelling. Family and social structures were seen as providing strong support, but limited the capacity of parents to influence children not to smoke. Marginalization was perceived to contribute to limited aspirations and opportunities, leading to pleasure-seeking in the present rather than having goals for the future.

CONCLUSIONS

The results support the importance of addressing contextual factors in any strategies aimed at preventing smoking initiation or supporting cessation among Aboriginal girls and women. It is critical to acknowledge Aboriginal identity and culture as a source of empowerment; and to recognise the role of persistent marginalization in contributing to the high prevalence and initiation of smoking.

"Back then" and "nowadays": social transition narratives in accounts of injecting drug use in an East European setting

Whereas most research investigating drug use transitions narrows its analyses around the individual and their decision-making, we explore how personal narratives of drug transition interplay with broader narratives of social and economic change in a 'transition society' of post-Soviet Europe. Informed by narrative theory, we draw upon analyses of 42 audio-recorded qualitative interviews conducted in the city of Balti, Moldova, in late 2009, with people with current and recent experience of injecting drug use. Accounts of drug transition connect with stories of shifting socio-economic conditions, drug markets, drug law enforcement practices, and social relationships across generations. Participants cast themselves as the 'transition generation', juxtaposing 'their' time of drug initiation "back then" with "nowadays". We find that personal stories of drug initiation, transition and career are told in relation to a meta-narrative of social transition. Whereas 'back then', drug use was depicted as 'natural', 'home-produced', embedded in social relations, and symbolically valuable, in the post-transition narrative of 'now', this culture of drug use has become disrupted, through the internationalisation of drug markets, the individualisation of social relations, the weakening of social ties and trust relations, flux in moral boundaries, and shifting social values of drug use. The meta-narrative of social transition serves to bridge biographical adaptation as collective experience. This helps to moderate the social harms linked to the 'becoming other' constituted by drug injecting, and bridge the effects of rationed expectation that can characterise post-Soviet transitions. We suggest that the narrative of transition offers a cultural script that says "transition is to blame".

Gender influences in tobacco use and cessation interventions

Smoking rates among and between men and women are in large part a reflection of the influence of gender and its intersections with other social factors including ethnicity, age, and social class that influence tobacco use and, ultimately, tobacco reduction and cessation. In this article, opportunities for developing and delivering gender-sensitive (programs addressing gender) and gender-specific (programs designed for men or women) interventions in the context of tobacco dependence treatment are discussed.

Narrating the social relations of initiating injecting drug use: transitions in self and society

Few studies have explored drug injectors' accounts of their initiation of others into injecting. There also lacks research on the social relations of initiating injecting drug use in transitional society. We draw upon analyses of 42 audio-recorded semi-structured interviews with current and recent injecting drug users, conducted in 2009 in the Republic of Moldova, a transitional society of south-eastern Europe. A thematic analysis informed by narrative theory was undertaken, focusing on accounts of self-initiation and the initiation of others. We also reflect upon the potential of peer efforts to dissuade would-be injectors from initiating. Findings emphasise initiation into injecting as a symbolic identity transition, enabled through everyday social relations. In turn, our analysis locates the drug transitions of the self inside an account of societal transition. We find that personal narratives of self transition are made sense of, and presented, in relation to broader narratives of social transition and change. Furthermore, we explore how narratives of self-initiation, and especially the initiation of others, serve to negotiate initiation as a moral boundary crossing. Self-initiation is located inside an account of transitioning social values. In looking back, initiation is depicted as a feature of a historically situated aberration in normative values experienced by the 'transition generation'. Accounts of the initiation of others (which a third of our sample describe) seek to qualify the act as acceptable given the circumstances. These accounts also connect the contingency of agency with broader narratives of social condition. Lastly, the power of peers to dissuade others from initiating injection was doubted, in part because most self-initiations were accomplished as a product of agency enabled by environment as well as in the face of peer attempts to dissuade.

Money is not enough: exploring the impact of social and cultural resources on youth health

BACKGROUND

Findings on socioeconomic health differentials in youth remain fragmented with the role of cumulative and interaction effects of different forms of health resources not well understood.

METHODS

European KIDSCREEN data were analysed to explore effects of material and non-material resources on subjective health in The Netherlands, Hungary, and the UK.

RESULTS

Regression analysis revealed significant main effects of economic, social, and cultural resources on youth health. In the UK an interaction effect between economic and cultural resources indicated a conditional relationship between material and non-material health resources.

CONCLUSIONS

Exploring the combined impact of economic, social, and cultural resources may contribute to our understanding of health differentials.

Visual storytelling: a beneficial but challenging method for health research with young people

Visual storytelling is a new research approach drawing on established methods of photovoice and photo elicitation. It appears well suited to research with young people. We explored the feasibility of this approach, reflecting on benefits and challenges encountered while using it during a study of chronic disease self-management in adolescents. During in-depth interviews, 68 participants were questioned about the value of visual storytelling. Thematic analysis was applied. Visual storytelling was valued for (a) being a draw card during recruitment and increasing positive feelings about the research; (b) being fun; (c) promoting self-understanding; and (d) promoting expression, communication, and focus during interviews. Deciding what to photograph was difficult. More time and effort was required by researchers than for a standard qualitative interview study. The technique facilitated rich interviews, drawing into focus details of young peoples' lives that otherwise might not have been discussed.

A qualitative study of young people's sources of cigarettes and attempts to circumvent underage sales laws

AIMS

To explore how young people continue to access cigarettes following an increase of the age of sale to 18 years and the implications for future smoking prevention policy and practice.

DESIGN

Qualitative study using 14 focus groups.

SETTING

Schools and community projects in disadvantaged areas of Birmingham, UK.

PARTICIPANTS

Eighty-five smokers and non-smokers aged 12-15 years.

MEASUREMENTS

Focus group topic guides.

FINDINGS

While young people did use social sources to access cigarettes, most obtained cigarettes from small local shops. Smoking and non-smoking participants knew which shops sold to underage children and what strategies to employ, suggesting a widespread acceptance of underage sales in some communities. Some young people bought directly from retailers, reporting that the retailers did not ask for identification. Some young people reported that retailers were complicit, knowingly selling to underage smokers. Young people waited outside shops and asked strangers to buy them cigarettes (proxy sales). Young people expressed cynicism about some shopkeepers' motives, who they believed knew that they were selling to under-18s, but did not care as long as they made a profit.

CONCLUSIONS

The ban in selling cigarettes to those under 18 in the United Kingdom appears to be easily circumvented, and one important route appears to be 'proxy sales' in which young people approach strangers outside retailers and ask them to purchase cigarettes on their behalf.

Drug-Intake Methods and Social Identity: The Use of Marijuana in Blunts Among Southeast Asian Adolescents and Emerging Adults

This article examines why Southeast Asian American adolescents and emerging adults in two urban settings prefer to use "blunts," or hollowed-out cigars filled with marijuana, over other methods of drug intake. Rationales for preferring blunts were both instrumental and social. Blunts allowed users to more easily share marijuana, the preferred drug among their peers, and protected against potential adverse effects associated with the "high." Blunts also allowed users to identify with the dominant style of drug use and differentiate themselves from users of stigmatized drugs such as crack cocaine and methamphetamine. This article highlights the importance of drug-intake methods in the formation and performance of drug-using behaviors among adolescents, emerging adults, and members of ethnic minority subgroups.

Breast cancer messaging for younger women: gender, femininity, and risk

Evidence linking both active smoking and secondhand smoke exposure to premenopausal breast cancer makes the development of health messages specific to younger women a pressing priority. To determine how to communicate information about this modifiable breast cancer risk to young women, we analyzed a selection of 32 recent English-language breast cancer messages and campaigns that targeted young women. In addition, we obtained young women's responses to three breast cancer campaign images during focus group discussions. A visual analysis of messages points to an explicitly gendered discourse within contemporary campaigns, one that entails conflicting messages regarding breast cancer, health, feminine beauty, and risk. Although the intent might be to educate and empower young women to "fight" against breast cancer, paradoxically, the messages employ imagery that sexually objectifies young women's breasts and bodies. Recommendations are made for messaging about tobacco and breast cancer risk to avoid reproducing one-dimensional or stereotypical presentations of gender and femininity.

The use of focus groups to compare tobacco attitudes and behaviors between youth in urban and rural settings

This exploratory study uses focus groups to examine the attitudes and behaviors of male adolescent tobacco users from urban and rural settings. Five focus groups, three urban and two rural, were conducted (n = 28). Results indicate that this is an interesting topic that generated interactions and discussion among participants. Themes that have emerged from the data include the sociability of tobacco initiation and access; tobacco preferences linked to image; social norms against secondhand smoke exposure, especially around children; ambivalence toward daily use as a habit versus an addiction; and avoidance of discussing cessation. The data from this study can help health departments distinguish and target prevention and intervention programs for youth in urban and rural settings.