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

Given evidence suggesting that most people who smoke begin during adolescence or in young adulthood [1–4], directing tobacco prevention efforts at youth is considered key for reducing long-term nicotine dependence and reducing the overall prevalence of smoking and related diseases [4, 5]. In the USA, mainstream approaches to youth tobacco use typically emphasize “risk and protective factors” and generally focus on changing individuals’ attitudes and beliefs to encourage cessation or prevent uptake of smoking [4, 6]. This may be done in several ways. For example, local community-level interventions, which work in tandem, attempt to counter personal and social factors, including stress, low self-esteem, peer pressure, and familial influences, that are putative predictors of youths’ smoking [7–9]. Such interventions include smoke-free ordinances, local anti-tobacco media campaigns, and school-, family-, and clinic-based interventions [4].

State-wide tobacco control approaches are also considered an important component of youth tobacco prevention. These include legislative and regulatory approaches that “address the social, economic, and environmental influences of tobacco use”—approaches which may extend existing local ordinances (e.g., minimum legal purchase age polices, smoke-free bans) or broadly implement new regulations and tobacco control efforts including increases in tobacco taxes and state-sponsored mass media campaigns designed to denormalize tobacco use and the tobacco industry among youth. Generally, these comprehensive approaches to youth tobacco prevention are considered highly effected in the movement towards a “tobacco endgame” [4].

Though these efforts are credited with significantly reducing smoking in the US general population [10, 11], smoking remains concentrated among the most disadvantaged groups [12–21], including sexual and gender minorities (SGM) [13, 22, 23]. Studies of tobacco use among SGM youth are limited [24, 25], yet available data suggest inequities similar to their adult counterparts. For example, in the 2015 Youth Risk Behavior Survey, sexual minority high school students in CA reported significantly more past-30-day cigarette smoking (~ 18%) and any past-30-day nicotine and tobacco use (i.e., cigarettes, smokeless tobacco, cigars, e-cigarettes) (~ 40%) than heterosexual students (~ 7%, ~ 27% respectively). Also, sexual minority high school students were significantly more likely to report having ever tried cigarette smoking (~ 46% compared with ~ 27%) [26]. Studies of gender minority youth are less common. However, a representative population-based study of middle and high school students in California found that transgender youth had almost five times greater odds of current cigarette smoking compared with cisgender youth, those youth whose gender identity corresponds to their sex assigned at birth [24]. Concern about the inequities inherent in who, statistically speaking, are more likely to smoke should occupy more of our focus in the tobacco field. Many scholars have highlighted the social gradient in smoking [13, 27], specifically among sexual and gender minorities [22, 23], yet tobacco control strategies remain largely focused on the general population [13, 18, 28].

A critical appraisal of two foundational components largely implicit in youth tobacco prevention strategies may be a useful starting point for investigating the causes that underlie smoking inequities among SGM youth. Take, for example, abstinence. Typically, abstinence is the only approach pursued for youth tobacco prevention in part due to concerns about the developmental risks of any tobacco use during adolescence. Though some approaches to tobacco control may be considered harm reduction strategies, most often abstinence is an explicitly-stated goal and discussions of reducing harm remain controversial, particularly when it comes to youth and young adults [29–32]. This runs counter to discourses in the prevention of drugs and alcohol where it is acknowledged that because some youth continue to use, comprehensive approaches that go beyond abstinence are necessary [33]. The controversy of harm reduction in the tobacco field arguably relates not just to the health risks presented but also concerns about the perception of “being in the service of big tobacco” [34] given the industry’s deceitful practices as well as fears that alternative approaches to tobacco prevention among youth may undermine achievements that have been made in tobacco control [29, 35]. Nevertheless, subscribing to a doctrine of abstinence, particularly given the available evidence from the drug and alcohol fields that illustrate its limitations, may only serve to reinforce smoking for some groups of youth. We cannot ignore the fact that some youth fail to “just say no” [29, 33], and that experimentation is a normal part of adolescence [29, 36–38].

A second foundational component arguably underlying mainstream youth tobacco prevention is an emphasis on future health [39, 40]. Diprose describes this type of approach as a “paradigm of preemption” shaped by a “cautious and fearful comportment toward the future it fosters” [41]. According to Keane, anti-tobacco approaches have “reduced [smoking] to its potentially most undesirable outcomes; namely, various premature, painful, and protracted forms of death” that will occur in the future [39]. The adoption of this approach for youth is surprising given extensive research documenting that “adolescents have weaker orientations toward the future, and thus they are poorer at…foreseeing long-term consequences” [42]. Therefore, for some young smokers “the seriously deleterious medical consequences of their habit lie in the future, while its rewards are experienced in the present” [39]. By focusing on future health, we are arguably failing to acknowledge youth as active agents, who also live in the ‘here-and-now’ [43], and likely, those who smoke, experience meaningful short-term benefits to smoking and place more emphasis on the perceived consequences of quitting in the present [44]. Also by emphasizing risk, smoking may become more, not less, attractive for some youth precisely because it is defined as harmful. For example, sociological research, examining the role of pleasure in drug use for youth, suggests that some youth seek to disrupt the mundane and rigid controls of everyday life by purposely engaging in “voluntary risk-taking” like drug use [45, 46]. In this same way, smoking may be one such activity where youth can “transform the routine and subvert the elements of control that take place in their everyday lives” [45].

This critique of mainstream approaches to tobacco prevention and policy warrants turning our attention to alternative approaches to studies of youths’ smoking and nicotine use—approaches that are critical in nature, highlight the agency of youth, and situate the practices of youth within a broader structural framework, considering these practices from youth’s own perspectives (see [47]). In other words, and for the purposes of this paper, what are the meanings of smoking for SGM youth themselves, particularly in the context of the structural inequities (e.g., racism, classism, sexism, homophobia) that are present in the everyday lives of some groups of young people? A significant body of social science research on youth and smoking, conducted primarily outside of the USA, highlights the unique meanings and roles of tobacco in the lives of youth, shedding light on why smoking persists despite quite widespread acknowledgement among youth about the health consequences of smoking. For example, qualitative studies have examined smoker identities among youth, illustrating the ways in which various smoker identities may be held by youth simultaneously, shifting over time and place, and that these identities are formed within a context where youth acknowledge both negative and positive meanings of smoking [6, 8, 48, 49]. Other studies have investigated the role smoking plays in identity construction more generally for youth, emphasizing youth as an authentic period of life that is not necessarily connected to adulthood [7, 40, 50–52]. Existing critical research on youth and tobacco has also centered structural inequity at its core, considering meanings of smoking with a broader structural framework, particularly emphasizing how economic disadvantage and gender, separately and at its intersections, shape meanings of tobacco and experiences with tobacco-related stigma [18, 50, 53–61]. Despite these important contributions and implications for public health, such studies appear to be largely overlooked in the tobacco field in the USA and rarely focus exclusively on the experiences of sexual and gender minority youth.

As such, more critical research on tobacco and nicotine use among SGM youth in the USA is needed if we hope to understand and prevent health inequities in smoking and related diseases. Furthermore, we would argue that more critical approaches to youth leisure practices, as developed within youth studies in general, may be useful for contextualizing and understanding the role of smoking among sexual and gender minority youth. For example, Griffin has argued that a critical perspective to youth research focuses “on the individual or collective cultural practices of particular young people as forms of resistance, defense and/or survival” [47], and by doing so, we can consider the connections between meanings of tobacco use and structural inequities experienced by SGM youth. In adopting such approaches, this paper aims to highlight the significance of situating the use of substances, in this case tobacco, within a broader structural framework. More specifically, using narrative data about smoking among 58 SGM youth in California, we will illustrate how themes of resistance, defense, and survival characterize youths’ narratives and highlight unique meanings of smoking for SGM youth. Most importantly, we will also discuss how those meanings may operate in opposition to mainstream approaches to tobacco prevention, treatment, and policy which may have the unintended consequences of sustaining inequities in smoking.

This analysis is based on the interview narratives from youth, who participated in a larger study investigating tobacco-related stigma and meanings of smoking for 201 SGM adults living in the San Francisco Bay Area (SF Bay Area). Fifty-eight young people, between the ages of 19–25, participated in in-depth qualitative interviews which included questions on the background of the participant; social identities; initiation, practices, and pathways of smoking; beliefs about smoking; motivations for smoking; and future intentions of use. In a background closed-ended screener, 73% identified as an ethnic minority and more than a quarter of participants reported past-month housing insecurity, suggesting variation in experiences with multiple disadvantages. Research staff were highly skilled in probing techniques and posing crucial follow up questions related to main study aims which introduced flexibility to the interview process so that narratives could be generated that were participant-driven.

All study procedures were approved by the Pacific Institute for Research and Evaluation’s Institutional Review Board, and all participants were briefed on ethical procedures and provided signed documentation of informed consent prior to participating. Participants were recruited on the street, through Facebook and Craigslist advertising, and by referral. To show our appreciation for their time, participants received a $55 honorarium upon completion of the interview. Interviews lasted approximately 2.5 h and were digitally recorded. Following each interview, research interviewers completed extensive fieldnotes summarizing the interview and noting potential emergent themes and connections or conflicts with other interviews. Interview recordings were professionally transcribed and three research assistants trained in critical social research reviewed, cleaned, and then coded all transcripts to distill data into manageable analytical segments, using ATLAS.ti, a qualitative data management system [62]. During coding and to ensure an iterative approach to analysis, the research team recorded preliminary analytical ideas about the data by attaching memos to segments of interview transcripts [63]. Themes emergent from memos informed multiple codebook revisions. The final code list was comprehensive, and codes selected for this analysis included smoking behaviors, perceptions of smoking, and reasons for smoking to scope the data into manageable analytic segments. All quotations associated with these three codes were analyzed by the lead and second authors, with constant reference to the fieldnotes for each participant to ensure interpretations were made within the context of each interview in its entirety. Quotations were sorted into piles of similarity identified according to principles of pattern-level analysis, including patterns congruent or divergent with prior theory, frequency of patterns, and omission of expected patterns to interpret to what extent meanings of smoking for young people may operate as forms of resistance, defense, and survival [64, 65].

Analysis of our participants’ narratives highlights how smoking is connected to the “‘here-and-now’ of young people’s experience, the social and cultural practices through which they shape their worlds” as active agents [43]. By interpreting young people’s narratives of smoking from an analytical lens that stresses resistance, survival, and defense, we will illustrate the meanings that young people ascribe to these practices—meanings that are frequently overlooked and therefore under-emphasized in tobacco prevention, treatment, and policy. In other words, we present these three themes as conceptual frames informed by youth studies within which participant perspectives may be interpreted in ways alternative to those dominating contemporary approaches to tobacco research and policymaking. These themes are not necessarily mutually exclusive, and it will become apparent that many of the quotes from our participants could be interpreted in multiple ways. However, for the sake of argument, we discuss them separately here to help clarify our main points about the incongruence between SGM youths’ perspectives on smoking and the perspectives of the orthodoxy which inform policies designed to control tobacco use. All quotations used below are presented with pseudonyms selected by participants to humanize narratives yet maintain anonymity.

Analysis of our participants’ narratives highlights how smoking is connected to the “‘here-and-now’ of young people’s experience, the social and cultural practices through which they shape their worlds” as agents [43]. As Hughes argues in his analysis of the “long-term development of tobacco use in the West,” contemporary tobacco use is largely considered “as an instrument of self control” [83]. Our studies of disadvantaged youth further justify this role of tobacco, where smoking signified 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. Tobacco prevention, treatment, and policy seldom acknowledges these meanings and the perceived benefits that youth associate with their tobacco use, instead situating youth as passive actors. Such an oversight, however, risks overlooking how tobacco use is grounded in youths’ everyday lives and not necessarily in their concern for their futures. We have presented participants’ narratives about their own smoking not from a perspective that situates tobacco use as a social and health problem but, instead, from a perspective that seeks to understand these practices from youth’s own perspectives and in concert with the structural context in which these youth live. Sexual and gender minority youth may ascribe radically different meanings to smoking compared with youth who experience more advantages in their day-to-day lives. However, if we hope to reduce inequities in smoking, these meanings must also be taken into consideration.

By taking a critical approach to our studies of youth smoking, it becomes clear how foundational elements underlying approaches to youth tobacco prevention and cessation, i.e., abstinence and an orientation to the future, specifically future health, may not necessarily resonate with all young people, particularly those who smoke because of the important perceived benefits that they can experience now. In fact, it may be the case that as long as tobacco prevention efforts continue to position smoking as a socially unacceptable practice and a threat to future health, some youth will remain drawn to smoking, either because messages fail to resonate with them or because the risks of stopping smoking at the moment feel greater than the risks smoking poses for future health [44, 81].

Not only is more research needed that takes a critical approach to studies of youth and tobacco in the United 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 efforts that are sensitive to the experiences of youth who continue to smoke, including SGM youth. Otherwise, we risk furthering the existing inequities in smoking. Perhaps this means making structural inequities and oppression a tobacco control issue. Perhaps this means explicitly pursuing harm reduction—where not all tobacco and nicotine products are treated as equally harmful—over abstinence in youth tobacco prevention, rather than remaining so focused on a “tobacco endgame” that we ignore the role that smoking plays in young people’s lives [32, 50, 103, 104]. Qualitative research suggests that vaping, for example, may be perceived by smokers to be an effective transitional tool for moving towards smoking cessation [105, 106], even for youth [29, 107, 108]. Yet to date, too little research has investigated to what extent vaping could serve as a suitable and potential replacement for smoking for youth, an omission perhaps explained in part by the negligible role of critically oriented tobacco research in policy and practice. However, if we hope to reduce inequities in smoking, “it is past time to add new and even radical approaches” ([29], p 14) and work towards a reality where the few who persist in smoking at least do so on an equitable playing field.