Smoking pockets, smoking islands – work in progress with ‘hardened smokers’

1. Smoking pockets, smoking islands – work in progress with ‘hardened smokers’ FrancesThirlway PhD student Centre for Medical Humanities School for Medicine & Health Durham University Supervisors: Professor Jane Macnaughton Dr Andrew Russell Dr Sue Lewis j.f.thirlway@durham.ac.uk

2. What are smoking islands ? • Socio-economic gradient in smoking (Jarvis & Wardle 2005) • Smokers are concentrated in particular neighbourhoods = ‘smoking islands’ (Thompson et al 2007) • Why does this matter ? Because... ‘Not fully understanding and accounting for socio-spatial disparities in smoking is...hampering tobacco control efforts’ (Poland et al 2006) • Poland et al characterise the social context of smoking as ‘the next frontier in tobacco control’ (2006) = ‘where, when and with whom’ we smoke

3. My research so far... • What qualitative research has been done on cigarette smoking in social context ? • What does it tell us ? • Studies of teenagers and young adults were excluded • tobacco use other than cigarettes was excluded

4. A systematic search • Search terms were variations on Smoking + qualitative + NOT teenager • Social context was not included at this stage to avoid missing relevant studies • Web of Knowledge, Medline, CINAHL, PsycINFO, EMBASE, , Anthropology Plus, JSTOR and IBBS • 7,445 articles found • 537 articles retained and reviewed in more detail • What did they cover ?

5. Which smokers have been studied ? Pregnancy & motherhood 80 Women 57 Indigenous/Aboriginal/First Nation/ Native Americans 47 Poverty and deprivation 43 Other ethnic minority groups in US 27 Mental health 25 COPD/Cancer/Diabetes/HIV & AIDS 22 African American 21 Smoke-free/second-hand smoke 18 Armed Forces 8 Prisoners 7 Latinos 6 LGBT 5 UK ethnic minorities 5 Drugs 3 Homelessness 1

6. How many studies looked at smoking in social context ? • Divided studies up into public context/private context • Found 13 studies which looked at the social context of smoking in the public sphere = where, when and with whom • Excluded studies often did little more than ask people their reasons for smoking which were... enjoyment, stress relief and boredom relief • These studies typically found that high-prevalence groups smoke more because they have... fewer pleasures, more stress and more boredom !

7. What key themes emerged from these studies ? • time and the smoker • Smoking spaces and places • the embodiment of smoking

8. Time and the smoker • To look at smoking in social context, studies looked at smoking in and over time, using life grids, diaries etc. • Relevance of the smoker’s time perspective and future orientation (Adams & White 2009, Lawlor et al 2003) • The daily ritual of smoking (Laurier 2000) • Smoking over the life course (Parry 2002)

9. Smoking places and spaces • Does denormalisation have any effect in smoking islands ? (= high prevalence neighbourhoods, but also prisons, psychiatric units, the military etc.) • Second-hand smoke and the policing of private space (homes, cars) • Smoke free legislation and the privatisation of smoking : a private pleasure or one shared with friends?

10. Smoking in the body • Very few studies examined the physical reality of smoking: inhaling and exhaling, taking smoke into the body, holding fire (Dennis 2009) • Studies which referred to the physicality of smoking only referred to stigma and spoilt identity: the smoker’s feelings of guilt, dirt, contamination, having to wash away the smell from mouth, hair and clothes (Haines et al 2010) • Gillies & Willig (1997): 'a more positive construction of the body, emphasising 'pleasure, strength, vitality', should replace views of the body as a 'dominant, controlling force (as in a discourse of addiction) or as a separate entity in need of regulation and repression (as in a construction of self-control). • Ettore  (1994): the experience of pleasure associated with the use of [drugs] needs to be replaced instead of denied, with strategies promoting sport or meditation as alternative forms of physical enjoyment.

11. Conclusion: what do we already know ? • Smokers are concentrated in deprived neighbourhoods and in special populations suffering from poverty and/or discrimination, stigma, mental illness etc. • Their reasons for smoking are the same as those of more prosperous smokers, but they are more addicted and find it harder to quit What does this study add ? • Very few qualitative studies have looked at smoking in social context, and more specifically at embodied smoking in time and space • Cessation services can benefit from a better understanding of where, when and with whom smoking takes place for high-prevalence groups, and tailor interventions accordingly.

12. How can we act on what we know? • Time and the smoker: influencing time perspective (improving self-esteem, treating depression, CBT) • Smoking places and spaces: addressing the normative smoking that exists in many neighbourhoods, institutions and populations. Group or population-level interventions may be more effective than individual cessation services here. • Smoking in the body: approaches that acknowledge the body might involve sport and exercise interventions • Addressing structural injustice: If we are serious about smoking cessation, we have a responsibility to address the poverty, inequality and discrimination which drive the need to self-medicate (also see Cooperstock & Lennard 1979).

13. References Adams J., White M.(2009)” Time perspective in socio-economic inequalities in smoking and bodymassindex”. Health Psychology 2009; 28: 83–90. Cooperstock, R., Lennard, H. L., (1979), “Some social meanings of tranquilizer use”. Sociology of Health & Illness, 1: 331–347 Dennis, S. (2005) “Four Milligrams of Phenomenology: An Anthrophenomenological Analysis of Smoking Cigarettes.“ Popular Culture Review Journal 15 (4): pp. 41-57. Ettorre, E. (1994) `Substance use and women's health', in S. Wilkinson and C. Kitzinger (eds), Women and Health: Feminist Perspectives, Taylor and Francis, London. Gillies, V. and C. Willig (1997). "'You get the nicotine and that in your blood': Constructions of addiction and control in women's accounts of cigarette smoking." Journal of Community & Applied Social Psychology7(4): 285-301. Haines, R. J., J. L. Oliffe, et al. (2010). "'The missing picture': tobacco use through the eyes of smokers." Tobacco Control19(3): 206-212. Jarvis M and Wardle J, “Social Patterning of individual health behaviours: the case of cigarette smoking”. In: Marmot M, Wilkinson R. Eds. Social Determinants of Health. Oxford, England: Oxford University Press, 2nd edition 2005 Laurier, E., L. McKie, et al. (2000). "Daily and lifecourse contexts of smoking." Sociology of Health & Illness22(3): 289-309. Lawlor, D., Frankel, S., et al (2003) “Smoking and ill-health: does lay epidemiology explain the failure of smoking cessation programs among deprived populations ?” American Journal of Public Health 93 (3): 266-270 Parry, O., C. Thomson, et al. (2002). "Cultural context, older age and smoking in Scotland: qualitative interviews with older smokers with arterial disease." Health Promotion International17(4): 309-316. Poland, B., K. Frohlich, et al. (2006). "The social context of smoking: the next frontier in tobacco control?" Tobacco Control15(1): 59-63. Thompson, L., J. Pearce, et al. (2007). "Moralising geographies: stigma, smoking islands and responsible subjects." Area39: 508-517.