Incorporating Intersectionality as a Framework for Equity-Minded Tobacco Control Research: A Call for Collective Action Toward a Paradigm Shift

INTRODUCTION

To eliminate tobacco-related disparities, tobacco control research would benefit from a paradigm shift. Intersectionality, a framework pioneered by Kimberlé Crenshaw in late 1980s, has the potential to improve our understanding of why and how certain social groups are disproportionately harmed by commercial tobacco use, and improve our ability to address persistent tobacco-related health disparities.

AIMS AND METHODS

In this commentary, we outline the rationale and recommendations for incorporating intersectionality into equity-minded tobacco control research. These recommendations arose from intersectionality webinars organized by the Health Disparities (now Health Equity) Network of the Society for Research on Nicotine & Tobacco (SRNT) in 2019 and 2020.

RESULTS

Specifically, we propose that eliminating tobacco-related disparities through intersectionality-informed research requires a multilevel, multipronged approach. We summarize priority actions for the tobacco control research field to achieve health equity through the intersectionality framework including acknowledging that structural factors, racism and power dynamics shape lived experiences, integrating critical theoretical frameworks and intersectionality scholarship into research questions, and embracing collaborative community-based approaches at every level of the research process.

CONCLUSIONS

Through these actions, our field can take concrete steps to fundamentally improve our approach to conducting research to achieve health equity.

IMPLICATIONS

Intersectionality is a valuable tool to align our field with our pursuit of health equity. The recommendations aim to improve methods of equity-focused tobacco control, prompt ongoing dialogue on the utility of this tool, and shift paradigms in how the research process is conducted at every level among stakeholders, including researchers, journal editors and reviewers, funders, practitioners, and policy makers.

Comparing conceptions of gender, sexuality and lesbian identity between baby boomers and millennials

To answer this special issue provocation, Is Lesbian Identity Obsolete? we analyzed interviews with people who had identified at some point in their lives as lesbians, or as women/femmes who were attracted to women - some of them part of the Baby Boomer generation and some part of the Millennial generation. Participants from both generations rejected the gender binary. Nevertheless, we found a shift away from understanding gender as an oppressive category to an understanding of gender as a proliferating identity in which one may play with gender in an intentional and creative manner. It appears that participants across generations articulated their sexual identities strategically to express not only a sexual orientation but more importantly political and community alliances. For Baby Boomer lesbians, lesbian identity connoted an alliance with feminism, and for Millennials their sexual identity indicated a political alliance with queer and trans* movements. In order to sustain solidarity between lesbians of different generations, we suggest that narratives about gender should include both intrinsic and extrinsic components. We further suggest that the political project of ending the oppression of all lesbians/women who love women is fraught, but essential in a world that hates women.

Intersecting Sexual Identities, Oppressions, and Social Justice Work: Comparing LGBTQ Baby Boomers to Millennials Who Came of Age After the 1980s AIDS Epidemic

In this study we analyze 50 interviews with racially diverse, predominantly low-income, LGBTQ participants living in the San Francisco Bay Area. Rooted in intersectional theory that conceptualizes identities as shaped by interlocking forms of oppression and privilege, we compared interviews with "Baby Boomers" to those with "Millennial" participants, who came into adulthood in a time of greater legal and social inclusion for LGBTQ people. Our analysis focused on three questions: How do participants understand their sexual identities? How are the identities of sexual minority participants co-constructed with intersecting forms of oppression? What motivates LGBTQ people in our sample to engage in social justice work? We found that white LGBTQ people tended to see their sexualities as primary to their identity, compared to LGBTQ Black and/or Indigenous People of Color (BIPOC) who tended to see their identities in intersectional terms. Younger LGBTQ people were more likely to delink sex and gender identity; consequently, they were more likely to frame their sexual identities with terms not rooted in a gender binary (e.g., pansexual or queer). Experiences with homophobia were prevalent across generations, and intersected with racism and economic oppressions, but younger people more often described support from institutional agents. Participants' sense of community and commitment to giving back after experiences of trauma motivated them to engage in social justice work. Our findings highlight the intersectional nature of oppressions faced by LGBTQ people and the need for organizations to move away from focusing exclusively on homophobic oppression as a monolith.

Trans adolescents' perceptions and experiences of their parents' supportive and rejecting behaviors

Transgender (trans) adolescents consistently report higher rates of adverse mental health outcomes compared to their cisgender peers. Parental support is a recognized adolescent protective factor; however, little is known about the specific parental behaviors that trans adolescents perceive as most or least supportive. To address this gap, we analyzed data from qualitative interviews conducted with an ethnically diverse, urban-based sample of trans adolescents (N = 24; 16-20 years old) to describe (a) the spectrum of specific parental behaviors across 3 categories-rejecting, supportive, and mixed (i.e., simultaneous supportive and rejecting behaviors)-and (b) the perceived psychosocial consequences across these 3 categories of parental behaviors. Qualitative data were gathered through lifeline interviews (i.e., visual representations from birth to present) and photo elicitation (i.e., photographs representing parental support and/or rejection). Supportive behaviors included instances where parents made independent efforts to learn about trans issues or help their child obtain gender-affirming health care. Rejecting behaviors included instances when parents refused to use their child's name or pronouns or failed to show empathy when their child struggled with gender-identity-related challenges. Mixed behaviors included examples when parents expressed support of their child's gender identity, but not of their sexual orientation (or vice versa). Overall, participants reported that rejecting and mixed parental behaviors contributed to a range of psychosocial problems (e.g., depression and suicidal ideation), while supportive behaviors increased positive wellbeing. These findings expand upon descriptions of parental support and rejection within the trans adolescent literature and can help practitioners target specific behaviors for interventions. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Is Smoking Queer? Implications of California Tobacco Denormalization Strategies for Queer Current and Former Smokers

This article is concerned with normative conceptions of health structuring tobacco control strategies designed to "denormalize" tobacco use. Analysis of 201 interviews with non-heterosexual and/or non-cisgender adults in California revealed that participants implicated tobacco use in exacerbating health inequities and perpetuating harmful narratives of queer suffering, but also regarded smoking as a critical tool for self-care and symbol of resistance. Participant narratives suggest that using stigma in health promotion efforts which reinforce normative conceptions of health may be harmful to queer people whose social identities exist within ongoing legacies of pathology, health stigma, and deviance from hegemonic structural norms.

Queer Youth, Intoxication and Queer Drinking Spaces

Research on intoxicating substances and gender has developed considerably in the last 30 years, especially in the social sciences as feminist scholars highlighted the contradictory discourses about young women's intoxication. Nevertheless, there still remain significant gaps if we are to fully understand the role and meaning of intoxication for all young people and not merely for heterosexual, cisgender young people. As a way of exploring the possible limitations of this legacy, we will examine the qualitative data from 52 in-depth interviews with self-identified LGBTQ young people. Our analysis explores the relationships between meanings of intoxication and sexual and gender identities, drinking spaces, and the extent to which notions of masculinity and femininity influence alcohol consumption and drinking practices among LGBTQ youth. As gender expressions among young people, especially those who identify as LGBTQ, become increasingly nuanced and fluid, understanding the role of social and cultural practices of alcohol consumption in the performance of sexual and gender identities may increase our understanding of the ways in which sexuality and gender influence alcohol consumption.

Conceptualizing ethnicity in alcohol and drug research: Epidemiology meets social theory

Since the 1990s, social scientists have rejected notions of ethnicity as something static and discrete, instead highlighting the context-dependent and fluid nature of multiple identities. In spite of these developments, researchers within the substance use fields continue to assess ethnic group categories in ways that suggest little critical reflection in terms of the validity of the measurements themselves, nor the social, bureaucratic, and political decisions shaping standard measures of ethnicity. This paper highlights these considerations, while also acknowledging the role of socially-delineated ethnic categorizations in documenting health inequities and social injustices. We call on researchers in alcohol and drugs research to critically appraise their use of ethnic categorizations, querying how to best measure ethnicity within their own studies in ways that are justified beyond simplified explanations of social convention and that "do no harm" in terms of perpetuating racism and obscuring the roots causes of social and health problems related to alcohol and drugs.

Taking Sides in E-cigarette Research

In the last ten years, an eclectic mix of electronic nicotine delivery products ('e-cigarettes') and practices have proliferated in the US with little restriction, producing a vast array of vaping mechanisms, flavors, and styles. At the same time, anti-tobacco movements have targeted e-cigarettes as a threat to public health and advocated for restricting e-cigarettes in much the same way as conventional cigarettes. While anti-vaping proponents associated with public health movements have typically regarded e-cigarettes as primarily harmful products that should be suppressed, vaping advocates regard e-cigarettes as harm reduction products that should be readily accessible to smokers. Distrust between these two warring "sides" animates the controversy over e-cigarettes. In our role as researchers conducting a qualitative study on e-cigarette use, we encountered suspicion and anger from members of an e-cigarette forum who felt that pro-vaping perspectives were often misrepresented by researchers. As a result, we dropped our initial plan to host a group discussion of questions directly related to our study on the forum. Nevertheless, the incident illuminated how vaping advocates have resisted dominant narratives regarding tobacco and nicotine use, destabilized nicotine product categories and challenged interpretations of nicotine use that dichotomize pleasure and health.

Effects of AlcoholEdu for college on alcohol-related problems among freshmen: a randomized multicampus trial

OBJECTIVE

AlcoholEdu for College is a 2- to 3-hour online course for incoming college freshmen. This study was the first multicampus trial to examine effects of AlcoholEdu for College on alcohol-related problems among freshmen.

METHOD

Thirty universities participated in the study. Fifteen were randomly assigned to receive AlcoholEdu, and the other 15 were assigned to the control condition. AlcoholEdu was implemented by intervention schools during the summer and/or fall semester. Cross-sectional surveys of freshmen were conducted at each university beginning before the intervention in spring 2008/2009; post-intervention surveys were administered in fall 2008/2009 and spring 2009/2010. The surveys included questions about the past-30-day frequency of 28 alcohol-related problems, from which we created indices for the total number of problems and problems in seven domains: physiological, academic, social, driving under the influence/ riding with drinking drivers, aggression, sexual risk taking, and victimization. Multilevel Poisson regression analyses were conducted to examine intent-to-treat and dosage effects of AlcoholEdu for College on these outcomes.

RESULTS

Multilevel intent-to-treat analyses indicated significant reductions in the risk for past-30-day alcohol problems in general and problems in the physiological, social, and victimization domains during the fall semester immediately after completion of the course. However, these effects did not persist in the spring semester. Additional analyses suggested stronger AlcoholEdu effects on these outcomes at colleges with higher rates of student course completion. No AlcoholEdu effects were observed for alcohol-related problems in the other four domains.

CONCLUSIONS

AlcoholEdu for College appears to have beneficial short-term effects on victimization and the most common types of alcohol-related problems among freshmen. Universities may benefit the most by mandating AlcoholEdu for College for all incoming freshmen and by implementing this online course along with environmental prevention strategies.

Evaluation of an Internet-based alcohol misuse prevention course for college freshmen: findings of a randomized multi-campus trial

BACKGROUND

Internet-based alcohol misuse prevention programs are now used by many universities. One popular 2- to 3-hour online course known as AlcoholEdu for College is typically required for all incoming freshmen and thus constitutes a campus-level strategy to reduce student alcohol misuse.

PURPOSE

Multi-campus study to evaluate the effectiveness of an Internet-based alcohol misuse prevention course.

DESIGN

RCT with 30 universities: 21 entered the study in Fall 2007, nine in Fall 2008. Fifteen were randomly assigned to receive the online course and the other 15 were assigned to the control condition. The course was implemented by intervention schools during the late summer and/or fall semester. Cross-sectional surveys of freshmen were conducted at each university, beginning prior to the intervention in Spring 2008-2009; post-intervention surveys were administered in Fall 2008-2009 and Spring 2009-2010.

SETTING/PARTICIPANTS

Public and private universities of varying sizes across the U.S. Random samples of 200 freshmen per campus were invited to participate in online surveys for the evaluation. Overall survey response rates ranged from 44% to 48% (M ≈ 90 participants per campus).

INTERVENTION

The online course includes five modules; the first four (Part I) are typically offered in the late summer before matriculation, and the fifth (Part II) in early fall. Course content includes defining a standard drink, physiologic effects of alcohol, the need to monitor blood alcohol level, social influences on alcohol use, alcohol laws, personalized normative feedback, and alcohol harm-reduction strategies. Students must pass an exam after Part I to advance to Part II.

MAIN OUTCOME MEASURES

Past-30-day alcohol use, average number of drinks per occasion, and binge drinking.

RESULTS

Multilevel intent-to-treat analyses indicated significant reductions in the frequency of past-30-day alcohol use (beta = -0.64, p<0.05) and binge drinking (beta = -0.26, p<0.05) during the fall semester immediately after completion of the course. However, these effects did not persist when assessed in the spring semester. Post hoc comparisons suggested stronger course effects on these outcomes at colleges with higher rates of student course completion. No course effects were observed for average number of drinks per occasion or prevalence of binge drinking, regardless of the campus course completion rate.

CONCLUSIONS

This study provides initial evidence that the Internet-based alcohol misuse prevention course has beneficial short-term effects on hazardous drinking behavior among first-year college students, which should be reinforced through effective environmental prevention strategies.

Distance and Beyond: Variables Influencing Conceptions of Food Store Accessibility in Baltimore, Maryland

This article is the result of a project conducted during my tenure with the Expanded Food and Nutrition Education Program (EFNEP). Before my hire, the director of EFNEP had hired a geographic information system (GIS) technician to create a GIS to spatially depict EFNEP clients' accessibility to food resources. By visually representing the relationship between low-income populations and the localities of food stores in Baltimore city, the GIS powerfully illustrated the relative lack of food resources in low-income areas of the city, suggesting serious obstacles to food access. However, when conceiving this type of GIS, it is essential to recognize that although geographic information systems can suggest potential hypotheses, drawing causal relationships between represented variables is problematic because GISs ignore the many behavioral and perceptual factors that affect human beings' decisions. For this reason, I was hired on a four-month contract to conduct an exploratory ethnographic project to complement the GIS.