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

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. Background and generally focus on changing individuals’ attitudes and Givenevidencesuggestingthatmostpeoplewhosmoke beliefs to encourage cessation or prevent uptake of smok- begin during adolescence or in young adulthood [1–4], ing [4, 6]. This may be done in several ways. For example, directing tobacco prevention efforts at youth is considered local community-level interventions, which work in key for reducing long-term nicotine dependence and redu- tandem, attempt to counter personal and social factors, in- cing the overall prevalence of smoking and related diseases cluding stress, low self-esteem, peer pressure, and familial [4, 5]. In the USA, mainstream approaches to youth to- influences, that are putative predictors of youths’ smoking bacco use typically emphasize “risk and protective factors” [7–9]. Such interventions include smoke-free ordinances, local anti-tobacco media campaigns, and school-, family-, and clinic-based interventions [4]. * Correspondence: tamar@criticalpublichealth.org; https://www.prev.org; State-wide tobacco control approaches are also consid- https://criticalpublichealth.org Critical Public Health Research Group, Prevention Research Center, 180 ered an important component of youth tobacco preven- Grand Ave, Suite 1200, Oakland, CA 94502, USA tion. These include legislative and regulatory approaches Center for Critical Public Health, Institute for Scientific Analysis, 1150 Ballena that “address the social, economic, and environmental Blvd, Suite 211, Alameda, CA 94501, USA © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Antin et al. Harm Reduction Journal (2018) 15:30 Page 2 of 11 influences of tobacco use”—approaches which may youth continue to use, comprehensive approaches that extend existing local ordinances (e.g., minimum legal go beyond abstinence are necessary [33]. The contro- purchase age polices, smoke-free bans) or broadly imple- versy of harm reduction in the tobacco field arguably ment new regulations and tobacco control efforts relates not just to the health risks presented but also including increases in tobacco taxes and state-sponsored concerns about the perception of “being in the service of mass media campaigns designed to denormalize tobacco big tobacco” [34] given the industry’s deceitful practices use and the tobacco industry among youth. Generally, as well as fears that alternative approaches to tobacco these comprehensive approaches to youth tobacco pre- prevention among youth may undermine achievements vention are considered highly effected in the movement that have been made in tobacco control [29, 35]. Never- towards a “tobacco endgame” [4]. theless, subscribing to a doctrine of abstinence, particu- Though these efforts are credited with significantly larly given the available evidence from the drug and reducing smoking in the US general population [10, 11], alcohol fields that illustrate its limitations, may only smoking remains concentrated among the most disad- serve to reinforce smoking for some groups of youth. vantaged groups [12–21], including sexual and gender We cannot ignore the fact that some youth fail to “just minorities (SGM) [13, 22, 23]. Studies of tobacco use say no” [29, 33], and that experimentation is a normal among SGM youth are limited [24, 25], yet available data part of adolescence [29, 36–38]. suggest inequities similar to their adult counterparts. For A second foundational component arguably under- example, in the 2015 Youth Risk Behavior Survey, sexual lying mainstream youth tobacco prevention is an minority high school students in CA reported signifi- emphasis on future health [39, 40]. Diprose describes cantly more past-30-day cigarette smoking (~ 18%) and this type of approach as a “paradigm of preemption” any past-30-day nicotine and tobacco use (i.e., cigarettes, shaped by a “cautious and fearful comportment toward smokeless tobacco, cigars, e-cigarettes) (~ 40%) than het- the future it fosters” [41]. According to Keane, erosexual students (~ 7%, ~ 27% respectively). Also, sex- anti-tobacco approaches have “reduced [smoking] to its ual minority high school students were significantly potentially most undesirable outcomes; namely, various more likely to report having ever tried cigarette smoking premature, painful, and protracted forms of death” that (~ 46% compared with ~ 27%) [26]. Studies of gender will occur in the future [39]. The adoption of this minority youth are less common. However, a representa- approach for youth is surprising given extensive research tive population-based study of middle and high school documenting that “adolescents have weaker orientations students in California found that transgender youth had toward the future, and thus they are poorer at…foresee- almost five times greater odds of current cigarette smok- ing long-term consequences” [42]. Therefore, for some ing compared with cisgender youth, those youth whose young smokers “the seriously deleterious medical conse- gender identity corresponds to their sex assigned at birth quences of their habit lie in the future, while its rewards [24]. Concern about the inequities inherent in who, sta- are experienced in the present” [39]. By focusing on tistically speaking, are more likely to smoke should future health, we are arguably failing to acknowledge occupy more of our focus in the tobacco field. Many youth as active agents, who also live in the ‘here-and-- scholars have highlighted the social gradient in smoking now’ [43], and likely, those who smoke, experience [13, 27], specifically among sexual and gender minorities meaningful short-term benefits to smoking and place [22, 23], yet tobacco control strategies remain largely more emphasis on the perceived consequences of quit- focused on the general population [13, 18, 28]. ting in the present [44]. Also by emphasizing risk, smok- A critical appraisal of two foundational components ing may become more, not less, attractive for some largely implicit in youth tobacco prevention strategies youth precisely because it is defined as harmful. For may be a useful starting point for investigating the example, sociological research, examining the role of causes that underlie smoking inequities among SGM pleasure in drug use for youth, suggests that some youth youth. Take, for example, abstinence. Typically, abstin- seek to disrupt the mundane and rigid controls of every- ence is the only approach pursued for youth tobacco day life by purposely engaging in “voluntary risk-taking” prevention in part due to concerns about the develop- like drug use [45, 46]. In this same way, smoking may be mental risks of any tobacco use during adolescence. one such activity where youth can “transform the rou- Though some approaches to tobacco control may be tine and subvert the elements of control that take place considered harm reduction strategies, most often abstin- in their everyday lives” [45]. ence is an explicitly-stated goal and discussions of redu- This critique of mainstream approaches to tobacco cing harm remain controversial, particularly when it prevention and policy warrants turning our attention to comes to youth and young adults [29–32]. This runs alternative approaches to studies of youths’ smoking and counter to discourses in the prevention of drugs and nicotine use—approaches that are critical in nature, alcohol where it is acknowledged that because some highlight the agency of youth, and situate the practices Antin et al. Harm Reduction Journal (2018) 15:30 Page 3 of 11 of youth within a broader structural framework, consid- narrative data about smoking among 58 SGM youth in ering these practices from youth’s own perspectives (see California, we will illustrate how themes of resistance, [47]). In other words, and for the purposes of this defense, and survival characterize youths’ narratives and paper, what are the meanings of smoking for SGM highlight unique meanings of smoking for SGM youth. youth themselves, particularly in the context of the Most importantly, we will also discuss how those mean- structural inequities (e.g., racism, classism, sexism, ings may operate in opposition to mainstream homophobia) that are present in the everyday lives of approaches to tobacco prevention, treatment, and policy some groups of young people? A significant body of which may have the unintended consequences of sus- social science research on youth and smoking, con- taining inequities in smoking. ducted primarily outside of the USA, highlights the unique meanings and roles of tobacco in the lives of Methods youth, shedding light on why smoking persists despite This analysis is based on the interview narratives from quite widespread acknowledgement among youth about youth, who participated in a larger study investigating the health consequences of smoking. For example, tobacco-related stigma and meanings of smoking for qualitative studies have examined smoker identities 201 SGM adults living in the San Francisco Bay Area among youth, illustrating the ways in which various (SF Bay Area). Fifty-eight young people, between the smoker identities may be held by youth simultaneously, ages of 19–25, participated in in-depth qualitative inter- shifting over time and place, and that these identities views which included questions on the background of are formed within a context where youth acknowledge the participant; social identities; initiation, practices, both negative and positive meanings of smoking [6, 8, and pathways of smoking; beliefs about smoking; moti- 48, 49]. Other studies have investigated the role smok- vations for smoking; and future intentions of use. In a ing plays in identity construction more generally for background closed-ended screener, 73% identified as an youth, emphasizing youth as an authentic period of life ethnic minority and more than a quarter of participants that is not necessarily connected to adulthood [7, 40, reported past-month housing insecurity, suggesting 50–52]. Existing critical research on youth and tobacco variation in experiences with multiple disadvantages. has also centered structural inequity at its core, consid- Research staff were highly skilled in probing techniques ering meanings of smoking with a broader structural and posing crucial follow up questions related to main framework, particularly emphasizing how economic study aims which introduced flexibility to the interview disadvantage and gender, separately and at its intersec- process so that narratives could be generated that were tions, shape meanings of tobacco and experiences with participant-driven. tobacco-related stigma [18, 50, 53–61]. Despite these All study procedures were approved by the Pacific important contributions and implications for public Institute for Research and Evaluation’s Institutional health, such studies appear to be largely overlooked Review Board, and all participants were briefed on eth- in the tobacco field in the USA and rarely focus ical procedures and provided signed documentation of exclusively on the experiences of sexual and gender informed consent prior to participating. Participants minority youth. were recruited on the street, through Facebook and As such, more critical research on tobacco and nico- Craigslist advertising, and by referral. To show our tine use among SGM youth in the USA is needed if we appreciation for their time, participants received a $55 hope to understand and prevent health inequities in honorarium upon completion of the interview. Inter- smoking and related diseases. Furthermore, we would views lasted approximately 2.5 h and were digitally argue that more critical approaches to youth leisure recorded. Following each interview, research inter- practices, as developed within youth studies in general, viewers completed extensive fieldnotes summarizing the may be useful for contextualizing and understanding the interview and noting potential emergent themes and role of smoking among sexual and gender minority connections or conflicts with other interviews. Interview youth. For example, Griffin has argued that a critical recordings were professionally transcribed and three re- perspective to youth research focuses “on the individual search assistants trained in critical social research or collective cultural practices of particular young people reviewed, cleaned, and then coded all transcripts to dis- as forms of resistance, defense and/or survival” [47], and till data into manageable analytical segments, using by doing so, we can consider the connections between ATLAS.ti, a qualitative data management system [62]. meanings of tobacco use and structural inequities expe- During coding and to ensure an iterative approach to rienced by SGM youth. In adopting such approaches, analysis, the research team recorded preliminary analyt- this paper aims to highlight the significance of situating ical ideas about the data by attaching memos to seg- the use of substances, in this case tobacco, within a ments of interview transcripts [63]. Themes emergent broader structural framework. More specifically, using from memos informed multiple codebook revisions. The Antin et al. Harm Reduction Journal (2018) 15:30 Page 4 of 11 final code list was comprehensive, and codes selected for cultures and marginalized youth has a long tradition this analysis included smoking behaviors, perceptions of both in the USA [72, 73] and in the UK [74–76], with smoking, and reasons for smoking to scope the data into much emphasis placed on the role of illicit drugs within manageable analytic segments. All quotations associated these subcultures. [69, 77–80] While some research has with these three codes were analyzed by the lead and examined smoking as a form of resistance for youth second authors, with constant reference to the fieldnotes (e.g., [50, 67, 81]), less research has focused its examin- for each participant to ensure interpretations were made ation on the ways in which tobacco use may be used by within the context of each interview in its entirety. Quo- sexual and gender minority youth to cultivate an alterna- tations were sorted into piles of similarity identified tive definition of self-identity to resist discrimination according to principles of pattern-level analysis, includ- and/or social isolation. ing patterns congruent or divergent with prior theory, In one conceptualization of resistance, a clear power frequency of patterns, and omission of expected patterns structure or “enemy” exists that a subgroup of youth is to interpret to what extent meanings of smoking for thought to fight against in more or less subversive ways. young people may operate as forms of resistance, The “oppressor” might be patriarchy or institutionalized defense, and survival [64, 65]. racism, or perhaps even a public health establishment Analysis of our participants’ narratives highlights that is perceived by some youth to be dominated by how smoking is connected to the “‘here-and-now’ of “crusaders” who do not always “tell the truth” [82]. In young people’s experience, the social and cultural these cases, resistance to oppression may involve youth practices through which they shape their worlds” as using “popular culture and aesthetic artifacts to fight active agents [43]. By interpreting young people’snar- against power” [66], and smoking may be one tool, albeit ratives of smoking from an analytical lens that not that powerful, to exert some control over their lives stresses resistance, survival, and defense, we will illus- through their activities. For example, SB, a 24-year-old trate the meanings that young people ascribe to these queer woman who used to smoke, explains: practices—meanings that are frequently overlooked and therefore under-emphasized in tobacco preven- You have this radius suddenly of control, …where tion, treatment, and policy. In other words, we you’re taking up space with the smoking…, which is present these three themes as conceptual frames cool…showing passersby[s], this is the four of us. This informed by youth studies within which participant is where we’re smoking right now. We’re talking. perspectives may be interpreted in ways alternative to We’re socializing. This is kind of our area at this those dominating contemporary approaches to to- moment, which is really appealing for queer folks. bacco research and policymaking. These themes are Like, sending a message to passersby[s] who we don’t not necessarily mutually exclusive, and it will become know, who might hate queers. …this is our space right apparent that many of the quotes from our partici- now…we’re communing. We’re socializing, and we’re pants could be interpreted in multiple ways. However, not alone. So, mess with us at your peril. And I’m for the sake of argument, we discuss them separately sure there’s a big appeal to that in a lot of ways…It’s here to help clarify our main points about the incon- an aggression born of fear. It’s something that I say gruence between SGM youths’ perspectives on smok- because I have been harassed as an individual for ing and the perspectives of the orthodoxy which being queer…But there is a lot of strength in inform policies designed to control tobacco use. All numbers. So yeah, […it’s] sort of a preemptive quotations used below are presented with pseudo- retaliation to people who would like to punish us. nyms selected by participants to humanize narratives yet maintain anonymity. Using cigarettes to control and occupy space emerged as a frequent pattern in participants’ narratives of smok- Results and Discussion ing. Other scholars have highlighted meanings of smok- Resistance ing as control [50, 81, 83], for example, in terms of The notion of resistance provides an important unifying establishing a sense of control while living in circum- thematic area to make sense of data that has emerged stances of disadvantage [55, 84] or exemplifying emo- from our analysis (see [66, 67]). In examining youth cul- tional control [44, 56, 83, 85]. In our participants’ tures, researchers have considered the ways in which narratives, control often manifested in ways that empha- youth groups develop subcultures based on values sized a desire to exert control over an oppressor, like opposed to or resisting the values of the dominant soci- SB’s quote illustrates. ety. [67–69] These subcultures are considered forms of However, a clear enemy need not be articulated for a resistance through which some marginalized youth tran- sense of resistance to be enacted [66]. For example, scend negative stereotypes. [69–71] Research on youth some participants’ narratives emphasized the deviancy Antin et al. Harm Reduction Journal (2018) 15:30 Page 5 of 11 socially ascribed to both queerness and smoking, power- smoking may be connected. The first is emotional fully linking the two so that together they functioned as survival. a way to resist social marginalization. For example, Janet, Though youth often discussed potential long-term a 25-year-old former smoker who identified her sexuality consequences of smoking, the short-term benefits asso- as queer, said: ciated with smoking for getting through the day-to-day, in terms of daily stress and anxiety, often outweighed For me, when I smoked, you have to go to a concerns about future health. For example, Gigi, a designated area. You’re already kind of the pariah or 25-year-old trans woman who is trying to cut back on whatever. But, then, you bond with the other pariahs her smoking, noted: that are stuck in there. That was part of the appeal. Like, okay. Well, smokers, like, you have something to Stress that I feel like I can’t control because it’s bond over by being excluded, (quick laugh) … It’s like, dependent upon another person, or another situation being gay is socially unacceptable for the longest time, that is larger than what I have in my control…Because but that doesn’t stop people from being gay. It just while I know that I can’t control it, I still desire to have makes them form their own gay community. So, answers, or to be able to control it. And I know that’s smokers are kind of, always been like their own one thing that makes me want the enjoyment that community. Like, when I go to a group of smokers, comes from smoking. I know, [smoking] at least it’s like, Yeah, yeah, yeah. I know exactly what you’re temporarily relieves that feeling, that’s what I associate doing out here…It’s something relatable. You know? it with. Here, Janet expresses how smoking serves to resist Other participants’ narratives situated their smoking in social isolation and cultivate community. Literature from terms of emotional survival within the context of coping critical research in the alcohol and drug fields illustrates with traumatic stress associated with everyday experi- the ways in which young people use particular commod- ences with discrimination and marginalization. For ities, like substances, as cultural markers to stake out example, Jen a 22-year-old former smoker, who identifies their identities in opposition to mainstream norms. The her sexuality as bisexual, talks about the value of smok- association between youth cultures and “deviant” sub- ing to survive within a heterosexist society. She plainly stance use has been noted by researchers as long ago as situates smoking as a tool for survival, something sup- the late 1950s when Finestone published Cats, Kicks and ported in literature on smoking among women living in Color [86], documenting the use of heroin, dress, style, circumstances of disadvantage [55]. and language among young African American drug users in Chicago (for additional work on youth cultures, sub- [LGBTQ] people’s lives are really hard. Just going stances and resistance (see [87]). Critical research on through it and making the most of it would probably tobacco has also emphasized how some youth may mean having a cigarette once in a while, because I’m adopt or maintain smoking precisely because it is posi- just going to do what I want in life. If what I have tioned as a deviant behavior by the same institutional gone through hasn’t killed me so far, …the cigarette is structures (e.g., normative health establishment) that probably not going to kill me. So it’s not really a high may already alienate youth who experience other forms priority for a lot of people to think about…I think if of social marginalization [50, 81, 84]. you are not out with your family…If you have to act straight to get through…your friends, your family or Survival colleagues, I think that adds a lot of stress to your life. While resistance may be argued as a political And yeah, just seeing the kind of violence that is out response to hegemonic structures, surviving may be there against LGBTQ people. It’s a really sad and conceptualized as something more fundamental to emotional thing…So I think they are much more life, something that is essential for getting through sensitive to that. Probably a lot more inclined to just the day. Survival may be about an individual and want to push that to the back of your mind and their well-being, life versus death, not acting out smoke a cigarette, get rid of the ideas and move on against but instead surviving within, with no inter- with their lives. pretation made about behaviors as related to resist- ance. Of course, some scholars have argued that just Similarly, a 23-year-old current smoker, who self-identified by virtue of surviving one “can signify a form of as a gay cisgender man but did not provide a pseudonym, resistance” in an oppressive culture [47]. Nevertheless, described a salient discriminatory experience in a clothing and for the sake of argument, narratives from our storearoundtheageof17whenhewas trying on dressesfor studies illustrated several ways in which survival and a school dance. Antin et al. Harm Reduction Journal (2018) 15:30 Page 6 of 11 I picked up one of the long dresses. I said, ‘ma’am, can “self-loathing”. In the 1980s and 1990s, scholars began I try this on in the changing room? I want to see if this to investigate pleasure and youth subcultures, where is gonna be my size, if it fits me’… She said, ‘excuse pleasure becomes a way to avoid or overcome the mun- me?’‘Well yeah, I want to try this on. I’m getting dane of everyday life [89–92]. However, here and in the ready for prom. We’re here picking out dresses’. She narratives of other participants, smoking as pleasure said, ‘no, I can’t let you do that. These are for women’s goes beyond just overcoming the mundane nature or only.’ Oh okay. I could have put that on the news, real routinization of everyday life, but also was emphasized quick. There would have been a whole problem, and as a tool for experiencing some pleasure within an in- she probably could have lost her job for discriminating equitable and oppressive society that feels beyond one’s against me….But, I decided to just put on the dress control. anyway. I was like ‘oh, it don’t fit (laughs). I think it’s Participants’ narratives also illustrated survival in gonna rip. Can you help me?’ The woman didn’twant terms of surviving socially. Literature in the tobacco field to help. My friends were there, just laughing. We’re all often talks about youths’ smoking in more passive terms, laughing….It’s crazy to see how people are so close specifically by emphasizing smoking as a result of peer minded or judgmental, or non-accepting of someone pressure. The implications of this interpretation, then, who wants to express themselves as who they are…My often results in individual-level prevention efforts that feelings weren’t hurt, but I’m pretty sure someone else “focus on cognitive factors that mitigate the effects of in that store, feelings could have been hurt, or someone peer group influences” [93]. However, narratives from could have been offended. And that’sthe sadpart.That our participants were more active, illustrating how made me want a cigarette. Like damn, you are that smoking was less connected to ‘I smoke because my fucked up, to feel that way towards me. And to be rude friends smoke’—though that was present in some narra- towards me. You stressed me out. Now I need a tives—and more connected to ‘I smoke to survive in cigarette. social situations’. For example, in the next quote, we further see how Jen, quoted above, also strategically used Day-to-day stressors, varying in degree of severity in smoking to connect with others. terms of their perceived consequences for mental and physical health, saturated participants’ narratives and My school was super conservative, really Christian…It were often explicitly linked to a need for smoking to was the exact opposite of me. So when I moved there, cope. I was really just reaching out to anybody who had any Intimately connected to emotional survival is pleasure, progressive, liberal in their body and anyone who is which is a rarely discussed attribute of smoking despite atheist. What is kind of interesting, the ones that its tremendous importance for smokers (e.g., [88]). For were more my type of people to talk to and have example, SB, introduced above, explained: conversations with, smoked. So that was something I ended up picking up just to talk with them…. Being queer in a heterosexist society is very stressful. I’m willing to bet – in fact, I can tell you definitively The emphasis here is less on peer pressure but in- that a lot of substance abuse within the queer stead on group solidarity and group identification. Of community is directly tied to that stress, to that sense course, there is a literature supportive of this notion of of comfort and support that is difficult to find outside sharing commodities and “intoxication” with others [in] the big brawn scary world. […] Just a sense of: (see [94–96]) where the focus is not on peer pressure this is something I can control. It feels good. I can but instead on the sociability that is shared when a sub- come back to it. I have control over it. It’s something I stance is consumed together. These are two very differ- can kind of take with me, when I go out into public. I ent interpretations on the role of substances of course, can still carry the feeling at least…It’s addressing I and these different interpretations are important, think stresses and anxieties and self-loathing that because while one emphasizes the agency of youth, the we’re socialized to accept in ourselves […] I can’t other sees young people as passive and easily able to change the society around me, but I can change the succumb to peer pressure (for a further discussion and way I feel. So, it was a misguided attempt to really critique of notions of peer pressure see [97]). take control over how I felt in that society that In a context of social marginalization, the importance seemed unwelcome of me. of group belonging also takes on additional meanings for our participants, where smoking facilitates entrée into Here, SB smokes because it “feels good” and she can certain groups where social acceptance is more likely. “carry” that pleasurable experience as a possible protec- Similarly, in their study of disadvantaged and socially tion from hate and as a palliative for “stress” and marginalized youth in Australia, Hefler and Carter [58] Antin et al. Harm Reduction Journal (2018) 15:30 Page 7 of 11 found that smoking served as a way for some socially Participants frequently described how they capitalized stigmatized youth to adopt a “compromise” identity in on the symbolic meanings associated with smoking— what they perceived to be a less than ideal social context e.g., as is the case with Marisol above, smoking as a sign but which for some youth nevertheless “provided some of strength and toughness [44, 56, 83]—to protect their sense of belonging” (p 11). gendered bodies by creating symbolic “safe” spaces A mainstream and rationalistic interpretation of these where they could more easily defend themselves from narratives of survival might only consider smoking as a potential harassment. Though some research has em- poor decision for coping with stress during this universal phasized the creation of spaces accepting of smoking in life stage that tends to be essentialized as a period of response to the stigmatization of smoking and arguably “stress and storm” [43, 98]. However, we would argue the smoker [8, 54, 60, 100], few studies have illustrated that it is also important to remember that youths’ expe- how smokers strategically use smoking to transform, at riences exist in the “here-and-now” and that for some least partially, “unsafe” spaces into “safe” spaces as youth, smoking is a particularly useful tool for alleviating defense against homophobia or sexism. Relying on feelings of anxiety and stress, particularly those stem- smoking for protection emerged not only for sexual ming from discriminatory treatment and trauma. As minority women in heteronormative spaces, but also for such, emphasizing future health in tobacco control and women in spaces defined by gay men and for gender prevention may do nothing to counter the value that non-conforming participants in a multitude of contexts some youth place on smoking for surviving and due to everyday threats of violence. A material object getting-by in the present. can shift “how an individual relates to and moves through “unsafe” space” [101]. In their synthesis of the Defense literature on “safe spaces”, the Roestone Collective [101] Finally, narratives of defense appeared frequently in argues that objects (like cigarettes for our purposes) can discussions related to youth perceptions about and “alter the constitution of and possibilities for safe reasons for smoking. In critical youth studies, dis- spaces,” and offer at least “incomplete solutions” for courses of defense (and survival, for that matter) defending against the oppressive structural conditions in emerged in response to critiques of resistance theory which some people find themselves (p 1360). which argued that researchers’ interpretations of so- Narratives of defense also emerged with respect to cial practices as forms of resistance “imbued [them] participants’ desires to protect their own health through with magisterial authority” and “carried the possibility the very act of smoking, a perspective that at first glance of romanticizing specific cultural practices as ‘resist- conflicts with normative conceptualizations of health ant’ which might also be sexist or racist or both” [47, and how best to protect it. For example, Ana, a 99]. When avoiding speculation about whether some 20-year-old current smoker who identifies their gender of our participants’ narratives about smoking illustrate as nonbinary trans and their sexuality as queer, acts of resistance, patterns of defense emerged illus- explained: trating how smoking is used strategically as a form of self-protection. For example, participants often dis- Working class people, folks of color and queers and cussed smoking as a way of creating “safe” space god forbid if you are all three of those things, you are around them to protect themselves from physical vio- going to be smoking. You are stressed out. There are lence and harassment. For example, Marisol, a not a lot of things that are accessible for you in terms 22-year-old queer woman said: of relief. Like, who can afford to get a massage every week? I can’t. Who can afford to get mental health …if I go out and I’m dressed up really femme and care? Sometimes smoking a cigarette is the difference people will usually think like, she can’t defend herself between…cutting myself or not. If I give myself that or whatever. And I feel like when I smoke cigarettes – ten-minute break, I don’t do that reactionary thing. So obviously there is this idea that you look tougher, that sometimes I think it is a coping mechanism. Some- you can actually beat someone up, even though that is times it’s the only one and it’s the best one that people not true. So, I think – if someone is harassing me or if have. I want to scare someone away, for some reason I feel like smoking a cigarette will be like, ‘don’t mess with While participants in general were not unaware of the me.’ You know?... I could do this when I’mata health risks that smoking posed, they nevertheless straight bar and I’m surrounded by straight people stressed the importance of smoking for mitigating and straight men are harassing me and I’m just trying serious mental health risks that they faced in the to basically make it seem like I could handle myself, present. Sociologists involved in research on youth and so get away from me. substance use (tobacco, alcohol, and illicit drugs) have Antin et al. Harm Reduction Journal (2018) 15:30 Page 8 of 11 emphasized the tendency by researchers to portray hope to reduce inequities in smoking, these meanings young people as passive and risky and, therefore, ir- must also be taken into consideration. rational. Consequently, youth are often considered in By taking a critical approach to our studies of youth need of protection from becoming the “victims of their smoking, it becomes clear how foundational elements own irresponsibility” [102]. However, given the variety of underlying approaches to youth tobacco prevention and risks that some young SGM participants may find them- cessation, i.e., abstinence and an orientation to the selves facing in the “here and now”—such as mental future, specifically future health, may not necessarily health crises, sexist violence, or lack of access to health resonate with all young people, particularly those who resources—smoking for these young people could in- smoke because of the important perceived benefits that stead be understood as an active and quite rational re- they can experience now. In fact, it may be the case that sponse. Thus, participants’ narratives from this study as long as tobacco prevention efforts continue to pos- highlight they ways in which these youth prioritize ition smoking as a socially unacceptable practice and a meaningful short-term benefits associated with smoking, threat to future health, some youth will remain drawn to in defense of their physical and mental health, over the smoking, either because messages fail to resonate with long-term physical health consequences that smoking them or because the risks of stopping smoking at the may pose. Indeed, for many participants, negotiations moment feel greater than the risks smoking poses for around smoking and health consequences involve con- future health [44, 81]. siderations of well-being that are much more complex Not only is more research needed that takes a critical and relative than can be recognized from the perspec- approach to studies of youth and tobacco in the United tives currently dominating tobacco control approaches. States, but it is also important that this more critically orientated research is a part of the conversation in developing innovative tobacco prevention and policy Conclusion efforts that are sensitive to the experiences of youth who Analysis of our participants’ narratives highlights how continue to smoke, including SGM youth. Otherwise, we smoking is connected to the “‘here-and-now’ of young risk furthering the existing inequities in smoking. people’s experience, the social and cultural practices Perhaps this means making structural inequities and op- through which they shape their worlds” as agents pression a tobacco control issue. Perhaps this means ex- [43]. As Hughes argues in his analysis of the “long-- plicitly pursuing harm reduction—where not all tobacco term development of tobacco use in the West,” con- and nicotine products are treated as equally harmful— temporary tobacco use is largely considered “as an over abstinence in youth tobacco prevention, rather than instrument of self control” [83]. Our studies of disad- remaining so focused on a “tobacco endgame” that we vantaged youth further justify this role of tobacco, ignore the role that smoking plays in young people’s where smoking signified control in a multitude of lives [32, 50, 103, 104]. Qualitative research suggests that ways, including taking control over an oppressor, con- vaping, for example, may be perceived by smokers to be trolling the effects of exposure to traumatic or an effective transitional tool for moving towards smok- day-to-day stress, and exerting control over the phys- ing cessation [105, 106], even for youth [29, 107, 108]. ical body in terms of protecting oneself from violence Yet to date, too little research has investigated to or defending one’s mental health. Tobacco prevention, what extent vaping could serve as a suitable and po- treatment, and policy seldom acknowledges these tential replacement for smoking for youth, an omis- meanings and the perceived benefits that youth asso- sion perhaps explained in part by the negligible role ciate with their tobacco use, instead situating youth of critically oriented tobacco research in policy and as passive actors. Such an oversight, however, risks practice. However, if we hope to reduce inequities in overlooking how tobacco use is grounded in youths’ smoking, “it is past time to add new and even radical everyday lives and not necessarily in their concern for approaches” ([29], p 14) and work towards a reality their futures. We have presented participants’ narra- where the few who persist in smoking at least do so tives about their own smoking not from a perspective on an equitable playing field. that situates tobacco use as a social and health prob- lem but, instead, from a perspective that seeks to understand these practices from youth’s own perspec- Endnotes tives and in concert with the structural context in Ana’s preferred pronouns are they/them/their. which these youth live. Sexual and gender minority youth may ascribe radically different meanings to Acknowledgements smoking compared with youth who experience more We are grateful to the 58 participants who willingly shared their time with advantages in their day-to-day lives. However, if we us. Without them, this research would not have been possible. Antin et al. Harm Reduction Journal (2018) 15:30 Page 9 of 11 Funding 8. Scheffels J. Stigma, or sort of cool young adults’ accounts of smoking and This research was supported by the National Cancer Institute of the National identity. Eur J Cult Stud. 2009;12:469–86. Institutes of Health under Award Number R01CA190238 and the Tobacco- 9. Stead M, Hastings G, Tudor-Smith C. Preventing adolescent smoking: a Related Disease Research Program (TRDRP) under grant number 24RT-0019. review of options. Health Educ J. 1996;55:31–54. The content is solely the responsibility of the authors and does not necessar- 10. Al-Delaimy WK, White MM, Mills AL, Pierce JP, Emory K, Boman M, Smith J, ily represent the official views of the National Institutes of Health or the Edland S. Final summary report of: two decades of the California Tob Tobacco-Related Disease Research Program. Control Program: California Tobacco Survey, 1990–2008. La Jolla, CA: University of California, San Diego; 2010. Availability of data and materials 11. Warner KE. 50 years since the first surgeon General’s report on smoking and The datasets generated and analyzed for the current study are not publicly health: a happy anniversary? Am J Public Health. 2014;104(1):5–8. available due to concerns about the potential for rich, qualitative narrative 12. Barbeau EM, Leavy-Sperounis A, Balbach ED. Smoking, social class, and data to be identifiable, regardless of efforts to redact clearly identifiable gender: what can public health learn from the tobacco industry about information (e.g., names, geographic locations connected to participants). disparities in smoking? Tob Control. 2004;13:115–20. However, upon reasonable request, the data may be shared directly from 13. Brown T, Platt S, Amos A. Equity impact of interventions and policies to the corresponding author. reduce smoking in youth: systematic review. Tob Control. 2014;23:e98–105. 14. CDC Office on Smoking and Health. Smoking and tobacco use; fact sheet; Authors’ contributions health effects of cigarette smoking. In: Smoking and Tobacco Use; 2013. TA and ES analyzed and interpreted all narrative data. TA and GH developed http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/ the conceptual framing for the manuscript. TA was a major contributor in effects_cig_smoking/. Accessed 2 Dec 2013. writing the manuscript, with assistance from GH and ES. All authors read and 15. Frohlich KL, Poland B, Mykhalovskiy E, Alexander S, Maule C. Tobacco approved the final manuscript. control and the inequitable socio-economic distribution of smoking: smokers’ discourses and implications for tobacco control. Crit Public Health. Ethics approval and consent to participate 2010;20:35–46. 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The “here and now” of youth: the meanings of smoking for sexual and gender minority youth

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Abstract

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. Background and generally focus on changing individuals’ attitudes and Givenevidencesuggestingthatmostpeoplewhosmoke beliefs to encourage cessation or prevent uptake of smok- begin during adolescence or in young adulthood [1–4], ing [4, 6]. This may be done in several ways. For example, directing tobacco prevention efforts at youth is considered local community-level interventions, which work in key for reducing long-term nicotine dependence and redu- tandem, attempt to counter personal and social factors, in- cing the overall prevalence of smoking and related diseases cluding stress, low self-esteem, peer pressure, and familial [4, 5]. In the USA, mainstream approaches to youth to- influences, that are putative predictors of youths’ smoking bacco use typically emphasize “risk and protective factors” [7–9]. Such interventions include smoke-free ordinances, local anti-tobacco media campaigns, and school-, family-, and clinic-based interventions [4]. * Correspondence: tamar@criticalpublichealth.org; https://www.prev.org; State-wide tobacco control approaches are also consid- https://criticalpublichealth.org Critical Public Health Research Group, Prevention Research Center, 180 ered an important component of youth tobacco preven- Grand Ave, Suite 1200, Oakland, CA 94502, USA tion. These include legislative and regulatory approaches Center for Critical Public Health, Institute for Scientific Analysis, 1150 Ballena that “address the social, economic, and environmental Blvd, Suite 211, Alameda, CA 94501, USA © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Antin et al. Harm Reduction Journal (2018) 15:30 Page 2 of 11 influences of tobacco use”—approaches which may youth continue to use, comprehensive approaches that extend existing local ordinances (e.g., minimum legal go beyond abstinence are necessary [33]. The contro- purchase age polices, smoke-free bans) or broadly imple- versy of harm reduction in the tobacco field arguably ment new regulations and tobacco control efforts relates not just to the health risks presented but also including increases in tobacco taxes and state-sponsored concerns about the perception of “being in the service of mass media campaigns designed to denormalize tobacco big tobacco” [34] given the industry’s deceitful practices use and the tobacco industry among youth. Generally, as well as fears that alternative approaches to tobacco these comprehensive approaches to youth tobacco pre- prevention among youth may undermine achievements vention are considered highly effected in the movement that have been made in tobacco control [29, 35]. Never- towards a “tobacco endgame” [4]. theless, subscribing to a doctrine of abstinence, particu- Though these efforts are credited with significantly larly given the available evidence from the drug and reducing smoking in the US general population [10, 11], alcohol fields that illustrate its limitations, may only smoking remains concentrated among the most disad- serve to reinforce smoking for some groups of youth. vantaged groups [12–21], including sexual and gender We cannot ignore the fact that some youth fail to “just minorities (SGM) [13, 22, 23]. Studies of tobacco use say no” [29, 33], and that experimentation is a normal among SGM youth are limited [24, 25], yet available data part of adolescence [29, 36–38]. suggest inequities similar to their adult counterparts. For A second foundational component arguably under- example, in the 2015 Youth Risk Behavior Survey, sexual lying mainstream youth tobacco prevention is an minority high school students in CA reported signifi- emphasis on future health [39, 40]. Diprose describes cantly more past-30-day cigarette smoking (~ 18%) and this type of approach as a “paradigm of preemption” any past-30-day nicotine and tobacco use (i.e., cigarettes, shaped by a “cautious and fearful comportment toward smokeless tobacco, cigars, e-cigarettes) (~ 40%) than het- the future it fosters” [41]. According to Keane, erosexual students (~ 7%, ~ 27% respectively). Also, sex- anti-tobacco approaches have “reduced [smoking] to its ual minority high school students were significantly potentially most undesirable outcomes; namely, various more likely to report having ever tried cigarette smoking premature, painful, and protracted forms of death” that (~ 46% compared with ~ 27%) [26]. Studies of gender will occur in the future [39]. The adoption of this minority youth are less common. However, a representa- approach for youth is surprising given extensive research tive population-based study of middle and high school documenting that “adolescents have weaker orientations students in California found that transgender youth had toward the future, and thus they are poorer at…foresee- almost five times greater odds of current cigarette smok- ing long-term consequences” [42]. Therefore, for some ing compared with cisgender youth, those youth whose young smokers “the seriously deleterious medical conse- gender identity corresponds to their sex assigned at birth quences of their habit lie in the future, while its rewards [24]. Concern about the inequities inherent in who, sta- are experienced in the present” [39]. By focusing on tistically speaking, are more likely to smoke should future health, we are arguably failing to acknowledge occupy more of our focus in the tobacco field. Many youth as active agents, who also live in the ‘here-and-- scholars have highlighted the social gradient in smoking now’ [43], and likely, those who smoke, experience [13, 27], specifically among sexual and gender minorities meaningful short-term benefits to smoking and place [22, 23], yet tobacco control strategies remain largely more emphasis on the perceived consequences of quit- focused on the general population [13, 18, 28]. ting in the present [44]. Also by emphasizing risk, smok- A critical appraisal of two foundational components ing may become more, not less, attractive for some largely implicit in youth tobacco prevention strategies youth precisely because it is defined as harmful. For may be a useful starting point for investigating the example, sociological research, examining the role of causes that underlie smoking inequities among SGM pleasure in drug use for youth, suggests that some youth youth. Take, for example, abstinence. Typically, abstin- seek to disrupt the mundane and rigid controls of every- ence is the only approach pursued for youth tobacco day life by purposely engaging in “voluntary risk-taking” prevention in part due to concerns about the develop- like drug use [45, 46]. In this same way, smoking may be mental risks of any tobacco use during adolescence. one such activity where youth can “transform the rou- Though some approaches to tobacco control may be tine and subvert the elements of control that take place considered harm reduction strategies, most often abstin- in their everyday lives” [45]. ence is an explicitly-stated goal and discussions of redu- This critique of mainstream approaches to tobacco cing harm remain controversial, particularly when it prevention and policy warrants turning our attention to comes to youth and young adults [29–32]. This runs alternative approaches to studies of youths’ smoking and counter to discourses in the prevention of drugs and nicotine use—approaches that are critical in nature, alcohol where it is acknowledged that because some highlight the agency of youth, and situate the practices Antin et al. Harm Reduction Journal (2018) 15:30 Page 3 of 11 of youth within a broader structural framework, consid- narrative data about smoking among 58 SGM youth in ering these practices from youth’s own perspectives (see California, we will illustrate how themes of resistance, [47]). In other words, and for the purposes of this defense, and survival characterize youths’ narratives and paper, what are the meanings of smoking for SGM highlight unique meanings of smoking for SGM youth. youth themselves, particularly in the context of the Most importantly, we will also discuss how those mean- structural inequities (e.g., racism, classism, sexism, ings may operate in opposition to mainstream homophobia) that are present in the everyday lives of approaches to tobacco prevention, treatment, and policy some groups of young people? A significant body of which may have the unintended consequences of sus- social science research on youth and smoking, con- taining inequities in smoking. ducted primarily outside of the USA, highlights the unique meanings and roles of tobacco in the lives of Methods youth, shedding light on why smoking persists despite This analysis is based on the interview narratives from quite widespread acknowledgement among youth about youth, who participated in a larger study investigating the health consequences of smoking. For example, tobacco-related stigma and meanings of smoking for qualitative studies have examined smoker identities 201 SGM adults living in the San Francisco Bay Area among youth, illustrating the ways in which various (SF Bay Area). Fifty-eight young people, between the smoker identities may be held by youth simultaneously, ages of 19–25, participated in in-depth qualitative inter- shifting over time and place, and that these identities views which included questions on the background of are formed within a context where youth acknowledge the participant; social identities; initiation, practices, both negative and positive meanings of smoking [6, 8, and pathways of smoking; beliefs about smoking; moti- 48, 49]. Other studies have investigated the role smok- vations for smoking; and future intentions of use. In a ing plays in identity construction more generally for background closed-ended screener, 73% identified as an youth, emphasizing youth as an authentic period of life ethnic minority and more than a quarter of participants that is not necessarily connected to adulthood [7, 40, reported past-month housing insecurity, suggesting 50–52]. Existing critical research on youth and tobacco variation in experiences with multiple disadvantages. has also centered structural inequity at its core, consid- Research staff were highly skilled in probing techniques ering meanings of smoking with a broader structural and posing crucial follow up questions related to main framework, particularly emphasizing how economic study aims which introduced flexibility to the interview disadvantage and gender, separately and at its intersec- process so that narratives could be generated that were tions, shape meanings of tobacco and experiences with participant-driven. tobacco-related stigma [18, 50, 53–61]. Despite these All study procedures were approved by the Pacific important contributions and implications for public Institute for Research and Evaluation’s Institutional health, such studies appear to be largely overlooked Review Board, and all participants were briefed on eth- in the tobacco field in the USA and rarely focus ical procedures and provided signed documentation of exclusively on the experiences of sexual and gender informed consent prior to participating. Participants minority youth. were recruited on the street, through Facebook and As such, more critical research on tobacco and nico- Craigslist advertising, and by referral. To show our tine use among SGM youth in the USA is needed if we appreciation for their time, participants received a $55 hope to understand and prevent health inequities in honorarium upon completion of the interview. Inter- smoking and related diseases. Furthermore, we would views lasted approximately 2.5 h and were digitally argue that more critical approaches to youth leisure recorded. Following each interview, research inter- practices, as developed within youth studies in general, viewers completed extensive fieldnotes summarizing the may be useful for contextualizing and understanding the interview and noting potential emergent themes and role of smoking among sexual and gender minority connections or conflicts with other interviews. Interview youth. For example, Griffin has argued that a critical recordings were professionally transcribed and three re- perspective to youth research focuses “on the individual search assistants trained in critical social research or collective cultural practices of particular young people reviewed, cleaned, and then coded all transcripts to dis- as forms of resistance, defense and/or survival” [47], and till data into manageable analytical segments, using by doing so, we can consider the connections between ATLAS.ti, a qualitative data management system [62]. meanings of tobacco use and structural inequities expe- During coding and to ensure an iterative approach to rienced by SGM youth. In adopting such approaches, analysis, the research team recorded preliminary analyt- this paper aims to highlight the significance of situating ical ideas about the data by attaching memos to seg- the use of substances, in this case tobacco, within a ments of interview transcripts [63]. Themes emergent broader structural framework. More specifically, using from memos informed multiple codebook revisions. The Antin et al. Harm Reduction Journal (2018) 15:30 Page 4 of 11 final code list was comprehensive, and codes selected for cultures and marginalized youth has a long tradition this analysis included smoking behaviors, perceptions of both in the USA [72, 73] and in the UK [74–76], with smoking, and reasons for smoking to scope the data into much emphasis placed on the role of illicit drugs within manageable analytic segments. All quotations associated these subcultures. [69, 77–80] While some research has with these three codes were analyzed by the lead and examined smoking as a form of resistance for youth second authors, with constant reference to the fieldnotes (e.g., [50, 67, 81]), less research has focused its examin- for each participant to ensure interpretations were made ation on the ways in which tobacco use may be used by within the context of each interview in its entirety. Quo- sexual and gender minority youth to cultivate an alterna- tations were sorted into piles of similarity identified tive definition of self-identity to resist discrimination according to principles of pattern-level analysis, includ- and/or social isolation. ing patterns congruent or divergent with prior theory, In one conceptualization of resistance, a clear power frequency of patterns, and omission of expected patterns structure or “enemy” exists that a subgroup of youth is to interpret to what extent meanings of smoking for thought to fight against in more or less subversive ways. young people may operate as forms of resistance, The “oppressor” might be patriarchy or institutionalized defense, and survival [64, 65]. racism, or perhaps even a public health establishment Analysis of our participants’ narratives highlights that is perceived by some youth to be dominated by how smoking is connected to the “‘here-and-now’ of “crusaders” who do not always “tell the truth” [82]. In young people’s experience, the social and cultural these cases, resistance to oppression may involve youth practices through which they shape their worlds” as using “popular culture and aesthetic artifacts to fight active agents [43]. By interpreting young people’snar- against power” [66], and smoking may be one tool, albeit ratives of smoking from an analytical lens that not that powerful, to exert some control over their lives stresses resistance, survival, and defense, we will illus- through their activities. For example, SB, a 24-year-old trate the meanings that young people ascribe to these queer woman who used to smoke, explains: practices—meanings that are frequently overlooked and therefore under-emphasized in tobacco preven- You have this radius suddenly of control, …where tion, treatment, and policy. In other words, we you’re taking up space with the smoking…, which is present these three themes as conceptual frames cool…showing passersby[s], this is the four of us. This informed by youth studies within which participant is where we’re smoking right now. We’re talking. perspectives may be interpreted in ways alternative to We’re socializing. This is kind of our area at this those dominating contemporary approaches to to- moment, which is really appealing for queer folks. bacco research and policymaking. These themes are Like, sending a message to passersby[s] who we don’t not necessarily mutually exclusive, and it will become know, who might hate queers. …this is our space right apparent that many of the quotes from our partici- now…we’re communing. We’re socializing, and we’re pants could be interpreted in multiple ways. However, not alone. So, mess with us at your peril. And I’m for the sake of argument, we discuss them separately sure there’s a big appeal to that in a lot of ways…It’s here to help clarify our main points about the incon- an aggression born of fear. It’s something that I say gruence between SGM youths’ perspectives on smok- because I have been harassed as an individual for ing and the perspectives of the orthodoxy which being queer…But there is a lot of strength in inform policies designed to control tobacco use. All numbers. So yeah, […it’s] sort of a preemptive quotations used below are presented with pseudo- retaliation to people who would like to punish us. nyms selected by participants to humanize narratives yet maintain anonymity. Using cigarettes to control and occupy space emerged as a frequent pattern in participants’ narratives of smok- Results and Discussion ing. Other scholars have highlighted meanings of smok- Resistance ing as control [50, 81, 83], for example, in terms of The notion of resistance provides an important unifying establishing a sense of control while living in circum- thematic area to make sense of data that has emerged stances of disadvantage [55, 84] or exemplifying emo- from our analysis (see [66, 67]). In examining youth cul- tional control [44, 56, 83, 85]. In our participants’ tures, researchers have considered the ways in which narratives, control often manifested in ways that empha- youth groups develop subcultures based on values sized a desire to exert control over an oppressor, like opposed to or resisting the values of the dominant soci- SB’s quote illustrates. ety. [67–69] These subcultures are considered forms of However, a clear enemy need not be articulated for a resistance through which some marginalized youth tran- sense of resistance to be enacted [66]. For example, scend negative stereotypes. [69–71] Research on youth some participants’ narratives emphasized the deviancy Antin et al. Harm Reduction Journal (2018) 15:30 Page 5 of 11 socially ascribed to both queerness and smoking, power- smoking may be connected. The first is emotional fully linking the two so that together they functioned as survival. a way to resist social marginalization. For example, Janet, Though youth often discussed potential long-term a 25-year-old former smoker who identified her sexuality consequences of smoking, the short-term benefits asso- as queer, said: ciated with smoking for getting through the day-to-day, in terms of daily stress and anxiety, often outweighed For me, when I smoked, you have to go to a concerns about future health. For example, Gigi, a designated area. You’re already kind of the pariah or 25-year-old trans woman who is trying to cut back on whatever. But, then, you bond with the other pariahs her smoking, noted: that are stuck in there. That was part of the appeal. Like, okay. Well, smokers, like, you have something to Stress that I feel like I can’t control because it’s bond over by being excluded, (quick laugh) … It’s like, dependent upon another person, or another situation being gay is socially unacceptable for the longest time, that is larger than what I have in my control…Because but that doesn’t stop people from being gay. It just while I know that I can’t control it, I still desire to have makes them form their own gay community. So, answers, or to be able to control it. And I know that’s smokers are kind of, always been like their own one thing that makes me want the enjoyment that community. Like, when I go to a group of smokers, comes from smoking. I know, [smoking] at least it’s like, Yeah, yeah, yeah. I know exactly what you’re temporarily relieves that feeling, that’s what I associate doing out here…It’s something relatable. You know? it with. Here, Janet expresses how smoking serves to resist Other participants’ narratives situated their smoking in social isolation and cultivate community. Literature from terms of emotional survival within the context of coping critical research in the alcohol and drug fields illustrates with traumatic stress associated with everyday experi- the ways in which young people use particular commod- ences with discrimination and marginalization. For ities, like substances, as cultural markers to stake out example, Jen a 22-year-old former smoker, who identifies their identities in opposition to mainstream norms. The her sexuality as bisexual, talks about the value of smok- association between youth cultures and “deviant” sub- ing to survive within a heterosexist society. She plainly stance use has been noted by researchers as long ago as situates smoking as a tool for survival, something sup- the late 1950s when Finestone published Cats, Kicks and ported in literature on smoking among women living in Color [86], documenting the use of heroin, dress, style, circumstances of disadvantage [55]. and language among young African American drug users in Chicago (for additional work on youth cultures, sub- [LGBTQ] people’s lives are really hard. Just going stances and resistance (see [87]). Critical research on through it and making the most of it would probably tobacco has also emphasized how some youth may mean having a cigarette once in a while, because I’m adopt or maintain smoking precisely because it is posi- just going to do what I want in life. If what I have tioned as a deviant behavior by the same institutional gone through hasn’t killed me so far, …the cigarette is structures (e.g., normative health establishment) that probably not going to kill me. So it’s not really a high may already alienate youth who experience other forms priority for a lot of people to think about…I think if of social marginalization [50, 81, 84]. you are not out with your family…If you have to act straight to get through…your friends, your family or Survival colleagues, I think that adds a lot of stress to your life. While resistance may be argued as a political And yeah, just seeing the kind of violence that is out response to hegemonic structures, surviving may be there against LGBTQ people. It’s a really sad and conceptualized as something more fundamental to emotional thing…So I think they are much more life, something that is essential for getting through sensitive to that. Probably a lot more inclined to just the day. Survival may be about an individual and want to push that to the back of your mind and their well-being, life versus death, not acting out smoke a cigarette, get rid of the ideas and move on against but instead surviving within, with no inter- with their lives. pretation made about behaviors as related to resist- ance. Of course, some scholars have argued that just Similarly, a 23-year-old current smoker, who self-identified by virtue of surviving one “can signify a form of as a gay cisgender man but did not provide a pseudonym, resistance” in an oppressive culture [47]. Nevertheless, described a salient discriminatory experience in a clothing and for the sake of argument, narratives from our storearoundtheageof17whenhewas trying on dressesfor studies illustrated several ways in which survival and a school dance. Antin et al. Harm Reduction Journal (2018) 15:30 Page 6 of 11 I picked up one of the long dresses. I said, ‘ma’am, can “self-loathing”. In the 1980s and 1990s, scholars began I try this on in the changing room? I want to see if this to investigate pleasure and youth subcultures, where is gonna be my size, if it fits me’… She said, ‘excuse pleasure becomes a way to avoid or overcome the mun- me?’‘Well yeah, I want to try this on. I’m getting dane of everyday life [89–92]. However, here and in the ready for prom. We’re here picking out dresses’. She narratives of other participants, smoking as pleasure said, ‘no, I can’t let you do that. These are for women’s goes beyond just overcoming the mundane nature or only.’ Oh okay. I could have put that on the news, real routinization of everyday life, but also was emphasized quick. There would have been a whole problem, and as a tool for experiencing some pleasure within an in- she probably could have lost her job for discriminating equitable and oppressive society that feels beyond one’s against me….But, I decided to just put on the dress control. anyway. I was like ‘oh, it don’t fit (laughs). I think it’s Participants’ narratives also illustrated survival in gonna rip. Can you help me?’ The woman didn’twant terms of surviving socially. Literature in the tobacco field to help. My friends were there, just laughing. We’re all often talks about youths’ smoking in more passive terms, laughing….It’s crazy to see how people are so close specifically by emphasizing smoking as a result of peer minded or judgmental, or non-accepting of someone pressure. The implications of this interpretation, then, who wants to express themselves as who they are…My often results in individual-level prevention efforts that feelings weren’t hurt, but I’m pretty sure someone else “focus on cognitive factors that mitigate the effects of in that store, feelings could have been hurt, or someone peer group influences” [93]. However, narratives from could have been offended. And that’sthe sadpart.That our participants were more active, illustrating how made me want a cigarette. Like damn, you are that smoking was less connected to ‘I smoke because my fucked up, to feel that way towards me. And to be rude friends smoke’—though that was present in some narra- towards me. You stressed me out. Now I need a tives—and more connected to ‘I smoke to survive in cigarette. social situations’. For example, in the next quote, we further see how Jen, quoted above, also strategically used Day-to-day stressors, varying in degree of severity in smoking to connect with others. terms of their perceived consequences for mental and physical health, saturated participants’ narratives and My school was super conservative, really Christian…It were often explicitly linked to a need for smoking to was the exact opposite of me. So when I moved there, cope. I was really just reaching out to anybody who had any Intimately connected to emotional survival is pleasure, progressive, liberal in their body and anyone who is which is a rarely discussed attribute of smoking despite atheist. What is kind of interesting, the ones that its tremendous importance for smokers (e.g., [88]). For were more my type of people to talk to and have example, SB, introduced above, explained: conversations with, smoked. So that was something I ended up picking up just to talk with them…. Being queer in a heterosexist society is very stressful. I’m willing to bet – in fact, I can tell you definitively The emphasis here is less on peer pressure but in- that a lot of substance abuse within the queer stead on group solidarity and group identification. Of community is directly tied to that stress, to that sense course, there is a literature supportive of this notion of of comfort and support that is difficult to find outside sharing commodities and “intoxication” with others [in] the big brawn scary world. […] Just a sense of: (see [94–96]) where the focus is not on peer pressure this is something I can control. It feels good. I can but instead on the sociability that is shared when a sub- come back to it. I have control over it. It’s something I stance is consumed together. These are two very differ- can kind of take with me, when I go out into public. I ent interpretations on the role of substances of course, can still carry the feeling at least…It’s addressing I and these different interpretations are important, think stresses and anxieties and self-loathing that because while one emphasizes the agency of youth, the we’re socialized to accept in ourselves […] I can’t other sees young people as passive and easily able to change the society around me, but I can change the succumb to peer pressure (for a further discussion and way I feel. So, it was a misguided attempt to really critique of notions of peer pressure see [97]). take control over how I felt in that society that In a context of social marginalization, the importance seemed unwelcome of me. of group belonging also takes on additional meanings for our participants, where smoking facilitates entrée into Here, SB smokes because it “feels good” and she can certain groups where social acceptance is more likely. “carry” that pleasurable experience as a possible protec- Similarly, in their study of disadvantaged and socially tion from hate and as a palliative for “stress” and marginalized youth in Australia, Hefler and Carter [58] Antin et al. Harm Reduction Journal (2018) 15:30 Page 7 of 11 found that smoking served as a way for some socially Participants frequently described how they capitalized stigmatized youth to adopt a “compromise” identity in on the symbolic meanings associated with smoking— what they perceived to be a less than ideal social context e.g., as is the case with Marisol above, smoking as a sign but which for some youth nevertheless “provided some of strength and toughness [44, 56, 83]—to protect their sense of belonging” (p 11). gendered bodies by creating symbolic “safe” spaces A mainstream and rationalistic interpretation of these where they could more easily defend themselves from narratives of survival might only consider smoking as a potential harassment. Though some research has em- poor decision for coping with stress during this universal phasized the creation of spaces accepting of smoking in life stage that tends to be essentialized as a period of response to the stigmatization of smoking and arguably “stress and storm” [43, 98]. However, we would argue the smoker [8, 54, 60, 100], few studies have illustrated that it is also important to remember that youths’ expe- how smokers strategically use smoking to transform, at riences exist in the “here-and-now” and that for some least partially, “unsafe” spaces into “safe” spaces as youth, smoking is a particularly useful tool for alleviating defense against homophobia or sexism. Relying on feelings of anxiety and stress, particularly those stem- smoking for protection emerged not only for sexual ming from discriminatory treatment and trauma. As minority women in heteronormative spaces, but also for such, emphasizing future health in tobacco control and women in spaces defined by gay men and for gender prevention may do nothing to counter the value that non-conforming participants in a multitude of contexts some youth place on smoking for surviving and due to everyday threats of violence. A material object getting-by in the present. can shift “how an individual relates to and moves through “unsafe” space” [101]. In their synthesis of the Defense literature on “safe spaces”, the Roestone Collective [101] Finally, narratives of defense appeared frequently in argues that objects (like cigarettes for our purposes) can discussions related to youth perceptions about and “alter the constitution of and possibilities for safe reasons for smoking. In critical youth studies, dis- spaces,” and offer at least “incomplete solutions” for courses of defense (and survival, for that matter) defending against the oppressive structural conditions in emerged in response to critiques of resistance theory which some people find themselves (p 1360). which argued that researchers’ interpretations of so- Narratives of defense also emerged with respect to cial practices as forms of resistance “imbued [them] participants’ desires to protect their own health through with magisterial authority” and “carried the possibility the very act of smoking, a perspective that at first glance of romanticizing specific cultural practices as ‘resist- conflicts with normative conceptualizations of health ant’ which might also be sexist or racist or both” [47, and how best to protect it. For example, Ana, a 99]. When avoiding speculation about whether some 20-year-old current smoker who identifies their gender of our participants’ narratives about smoking illustrate as nonbinary trans and their sexuality as queer, acts of resistance, patterns of defense emerged illus- explained: trating how smoking is used strategically as a form of self-protection. For example, participants often dis- Working class people, folks of color and queers and cussed smoking as a way of creating “safe” space god forbid if you are all three of those things, you are around them to protect themselves from physical vio- going to be smoking. You are stressed out. There are lence and harassment. For example, Marisol, a not a lot of things that are accessible for you in terms 22-year-old queer woman said: of relief. Like, who can afford to get a massage every week? I can’t. Who can afford to get mental health …if I go out and I’m dressed up really femme and care? Sometimes smoking a cigarette is the difference people will usually think like, she can’t defend herself between…cutting myself or not. If I give myself that or whatever. And I feel like when I smoke cigarettes – ten-minute break, I don’t do that reactionary thing. So obviously there is this idea that you look tougher, that sometimes I think it is a coping mechanism. Some- you can actually beat someone up, even though that is times it’s the only one and it’s the best one that people not true. So, I think – if someone is harassing me or if have. I want to scare someone away, for some reason I feel like smoking a cigarette will be like, ‘don’t mess with While participants in general were not unaware of the me.’ You know?... I could do this when I’mata health risks that smoking posed, they nevertheless straight bar and I’m surrounded by straight people stressed the importance of smoking for mitigating and straight men are harassing me and I’m just trying serious mental health risks that they faced in the to basically make it seem like I could handle myself, present. Sociologists involved in research on youth and so get away from me. substance use (tobacco, alcohol, and illicit drugs) have Antin et al. Harm Reduction Journal (2018) 15:30 Page 8 of 11 emphasized the tendency by researchers to portray hope to reduce inequities in smoking, these meanings young people as passive and risky and, therefore, ir- must also be taken into consideration. rational. Consequently, youth are often considered in By taking a critical approach to our studies of youth need of protection from becoming the “victims of their smoking, it becomes clear how foundational elements own irresponsibility” [102]. However, given the variety of underlying approaches to youth tobacco prevention and risks that some young SGM participants may find them- cessation, i.e., abstinence and an orientation to the selves facing in the “here and now”—such as mental future, specifically future health, may not necessarily health crises, sexist violence, or lack of access to health resonate with all young people, particularly those who resources—smoking for these young people could in- smoke because of the important perceived benefits that stead be understood as an active and quite rational re- they can experience now. In fact, it may be the case that sponse. Thus, participants’ narratives from this study as long as tobacco prevention efforts continue to pos- highlight they ways in which these youth prioritize ition smoking as a socially unacceptable practice and a meaningful short-term benefits associated with smoking, threat to future health, some youth will remain drawn to in defense of their physical and mental health, over the smoking, either because messages fail to resonate with long-term physical health consequences that smoking them or because the risks of stopping smoking at the may pose. Indeed, for many participants, negotiations moment feel greater than the risks smoking poses for around smoking and health consequences involve con- future health [44, 81]. siderations of well-being that are much more complex Not only is more research needed that takes a critical and relative than can be recognized from the perspec- approach to studies of youth and tobacco in the United tives currently dominating tobacco control approaches. States, but it is also important that this more critically orientated research is a part of the conversation in developing innovative tobacco prevention and policy Conclusion efforts that are sensitive to the experiences of youth who Analysis of our participants’ narratives highlights how continue to smoke, including SGM youth. Otherwise, we smoking is connected to the “‘here-and-now’ of young risk furthering the existing inequities in smoking. people’s experience, the social and cultural practices Perhaps this means making structural inequities and op- through which they shape their worlds” as agents pression a tobacco control issue. Perhaps this means ex- [43]. As Hughes argues in his analysis of the “long-- plicitly pursuing harm reduction—where not all tobacco term development of tobacco use in the West,” con- and nicotine products are treated as equally harmful— temporary tobacco use is largely considered “as an over abstinence in youth tobacco prevention, rather than instrument of self control” [83]. Our studies of disad- remaining so focused on a “tobacco endgame” that we vantaged youth further justify this role of tobacco, ignore the role that smoking plays in young people’s where smoking signified control in a multitude of lives [32, 50, 103, 104]. Qualitative research suggests that ways, including taking control over an oppressor, con- vaping, for example, may be perceived by smokers to be trolling the effects of exposure to traumatic or an effective transitional tool for moving towards smok- day-to-day stress, and exerting control over the phys- ing cessation [105, 106], even for youth [29, 107, 108]. ical body in terms of protecting oneself from violence Yet to date, too little research has investigated to or defending one’s mental health. Tobacco prevention, what extent vaping could serve as a suitable and po- treatment, and policy seldom acknowledges these tential replacement for smoking for youth, an omis- meanings and the perceived benefits that youth asso- sion perhaps explained in part by the negligible role ciate with their tobacco use, instead situating youth of critically oriented tobacco research in policy and as passive actors. Such an oversight, however, risks practice. However, if we hope to reduce inequities in overlooking how tobacco use is grounded in youths’ smoking, “it is past time to add new and even radical everyday lives and not necessarily in their concern for approaches” ([29], p 14) and work towards a reality their futures. We have presented participants’ narra- where the few who persist in smoking at least do so tives about their own smoking not from a perspective on an equitable playing field. that situates tobacco use as a social and health prob- lem but, instead, from a perspective that seeks to understand these practices from youth’s own perspec- Endnotes tives and in concert with the structural context in Ana’s preferred pronouns are they/them/their. which these youth live. Sexual and gender minority youth may ascribe radically different meanings to Acknowledgements smoking compared with youth who experience more We are grateful to the 58 participants who willingly shared their time with advantages in their day-to-day lives. However, if we us. Without them, this research would not have been possible. Antin et al. Harm Reduction Journal (2018) 15:30 Page 9 of 11 Funding 8. Scheffels J. Stigma, or sort of cool young adults’ accounts of smoking and This research was supported by the National Cancer Institute of the National identity. Eur J Cult Stud. 2009;12:469–86. Institutes of Health under Award Number R01CA190238 and the Tobacco- 9. Stead M, Hastings G, Tudor-Smith C. Preventing adolescent smoking: a Related Disease Research Program (TRDRP) under grant number 24RT-0019. review of options. Health Educ J. 1996;55:31–54. The content is solely the responsibility of the authors and does not necessar- 10. Al-Delaimy WK, White MM, Mills AL, Pierce JP, Emory K, Boman M, Smith J, ily represent the official views of the National Institutes of Health or the Edland S. Final summary report of: two decades of the California Tob Tobacco-Related Disease Research Program. Control Program: California Tobacco Survey, 1990–2008. La Jolla, CA: University of California, San Diego; 2010. Availability of data and materials 11. Warner KE. 50 years since the first surgeon General’s report on smoking and The datasets generated and analyzed for the current study are not publicly health: a happy anniversary? Am J Public Health. 2014;104(1):5–8. available due to concerns about the potential for rich, qualitative narrative 12. Barbeau EM, Leavy-Sperounis A, Balbach ED. Smoking, social class, and data to be identifiable, regardless of efforts to redact clearly identifiable gender: what can public health learn from the tobacco industry about information (e.g., names, geographic locations connected to participants). disparities in smoking? Tob Control. 2004;13:115–20. However, upon reasonable request, the data may be shared directly from 13. Brown T, Platt S, Amos A. Equity impact of interventions and policies to the corresponding author. reduce smoking in youth: systematic review. Tob Control. 2014;23:e98–105. 14. CDC Office on Smoking and Health. Smoking and tobacco use; fact sheet; Authors’ contributions health effects of cigarette smoking. In: Smoking and Tobacco Use; 2013. TA and ES analyzed and interpreted all narrative data. TA and GH developed http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/ the conceptual framing for the manuscript. TA was a major contributor in effects_cig_smoking/. Accessed 2 Dec 2013. writing the manuscript, with assistance from GH and ES. All authors read and 15. Frohlich KL, Poland B, Mykhalovskiy E, Alexander S, Maule C. Tobacco approved the final manuscript. control and the inequitable socio-economic distribution of smoking: smokers’ discourses and implications for tobacco control. Crit Public Health. Ethics approval and consent to participate 2010;20:35–46. 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Harm Reduction JournalSpringer Journals

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