Eliciting the smoker's agenda: implications for policy and practice

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Abstract

Existing health promotion messages and advice on smoking cessation focus upon the negative aspects of continuing to smoke and contrast these to the benefits of giving up. Benefits of cessation are invariably linked to reduced risks of illness and disease with the process of cessation framed as a largely positive and certainly a health enhancing one.

In this paper we present an analysis of data from a cross-sectional, exploratory study in the city of Aberdeen, Scotland, undertaken with 54 people, aged 18–44, who are or have been smokers. The multiple and often contradictory agendas of everyday life, smoking and health are explored. Participants spoke of the dangers of smoking and the potential benefits of giving up as these are considered by health promotion and medical research. However, many smokers experienced a number of benefits from smoking (such as socialising with others and breaks from boredom), and health and social problems with the process of cessation (for example, weight gain, stress, colds, flu). Participants appeared to query the validity of the risks of continuing to smoke and yet indicate a range of health and social difficulties in giving up.

The authors assert that an acknowledgement of the attractive, pleasurable aspects of smoking may be seen as unacceptable and irresponsible but this could well provide an opportunity to relate to the everyday and multiple practices of smoking and smokers themselves as illuminated by this research.

Introduction

The overall aim of the research reported in this paper was to elicit the ways in which people who are or have been smokers conceptualise the relationship between smoking and health and the implications of the smoker's agenda for the development of smoking cessation and health promotion services. The relevance of this research is in its potential to inform health and health promotion policies and practices from the perspective of current and ex-smokers. How do their experiences and perceptions of smoking and smoking cessation differ from or complement those of the health care practitioner and health promotion?

Research has shown smoking to be associated with many of the major causes of premature adult death in the Western world, being linked to an increased incidence of many cancers and associated with stroke and ischaemic heart disease (Smith, Tunstall, Crombie, & Tavendale, 1989; Doll & Peto, 1976; Doll, Peto, Wheatly, Gray, & Sutherland, 1994; Department of Health (1998b), Department of Health (1998a); Sato, 1999; Peto et al., 2000). In Scotland, over 13,000 people die each year as a result of smoking and the annual inpatient costs of illnesses due to smoking are about £77 million (Bostock, 1991; Amos & Hillhouse, 1992; Health Education Board for Scotland, 1995; ASH Scotland & Health Education Board for Scotland, 1998; Callum, 1998). While most smokers are aware of the dangers of smoking many will make multiple unsuccessful attempts to quit before succeeding (Coleman & Wilson, 1999; Lancaster, Stead, Silagy, & Sowden, 2000).

Research by Peto et al. (2000) estimates that current cigarette smoking will cause about 450 million deaths worldwide in the next 50 years. Preventing people from starting smoking would cut the number of deaths but not for 50 years or so. Quitting is the major way in which mortality rates from tobacco related diseases may be reduced in the medium term (Lancaster et al., 2000). However, while many smokers are aware of the dangers of smoking, most, as noted, will still make multiple attempts to quit and these attempts may or may not be successful (Coleman & Wilson, 1999; Lancaster et al., 2000).

Section snippets

Reflexivity, risk and smoking

The increasing focus upon health promotion and prevention, largely in the context of primary health care, has provoked debates over the extension of ‘medical gaze’ further into people's life worlds with suggestions that it forms an expression of governmentality into civil society (Foucault, 1991; Armstrong, 1995; Peterson & Bunton, 1997). The dissolution of the boundary between health and illness, most evident in the context of smoking cessation and screening services in primary health care,

The study

This was a cross-sectional, exploratory study. The research was conducted in Aberdeen City with 54 participants aged 18–44 who ranged across the social classes. The design was appropriate to a project, which sought to enhance our understandings of the processes involved in smoking cessation. The multiple and often contradictory agendas of everyday life required a flexible framework allowing a process of interpretation and re-interpretation. This requirement, premised upon the work of Glaser and

Findings

A range of themes emerged from the analysis (McKie, Scott, Taylor, & Laurier, 1998). Given the constraints of space in this paper we concentrate upon the place of smoking in everyday practices coupled with longer-term assessments of health and well-being, risk and stigma. Our aim is to illuminate the complex and dynamic discourses of smokers and ex-smokers and how these overlap and differ from those of health promotion and health professionals. In the subsequent sections we present data on,

The multiple practices of smoking

Smoking can shift from being an unremarkable daily activity to being loaded with symbolic significance. Just as eating can mean many different things according to what foods are involved, when, where, how and with whom it takes place, so it is with smoking. Smoking is a multiple practice that can be about reminiscing, relaxing or avoiding eating; to cite just a few salient ways it is woven into everyday life.

Health and well-being

For the self, smoking occupies a position between an activity of self-indulgence, self-protection and comfort and on the other hand self-harm, self-destruction and guilt (Graham 1993; Greaves, 1996). At times these contradictions can be kept in equilibrium by smokers, and at other times they cause feelings of conflict and dis-satisfaction. Giving up re-aligns these relations and is assessed often by an ‘improving’ physicality (vitality). The return of a sense of taste and improvements in the

Assessing the risks

It was clear from the participants’ experiences that they had been exposed to health promotional material on cigarette smoking. Testing their accuracy of their recall of that material was not an objective of the study. However, many spoke of smoking cessation materials. There was common agreement that smoking was bad for you, as a traffic warden explained it;

Int: Did you come across any of that kind of health promotion sort of material? You know the Health Education Board…

M: yeah, there was a

Stigma

Aside from the stigma attached in everyday discourse to smoking as a ‘filthy, dirty, polluting’ habit, its antonymical status with health left some of our participants expressing a sense of iniquitous treatment from the health care system. Several told of incidents with their local G.P.s and hospital-based doctors where smoking had been used to avoid offering a proper diagnosis and/or laying blame for illness at the feet of the sufferer since they smoked. Two examples include:

J: Well a friend

Discussion

Over the four sections of findings data presented illuminates how smokers explain their current smoking status. In the first section on socialising, an early part of the interview schedule, data are assertive in content and clear with regards to the role of smoking in a range of everyday and life-time practices. However, when asked to consider the health implications and risks associated with smoking explanations and narratives became contradictory. This highlights how consideration of these

Conclusions: implications for policy and practice

People are well aware of health promotion messages on smoking and it would seem that the population approach to cessation advice has succeeded well. Yet information and, in particular information on the health risks of smoking, did not necessarily lead to change or a re-assessment of smoking behaviour. In contrast it could lead to comparators of risk that have a place in folklore (being run over by a bus) and the dismissal of available epidemiological data. Ironically smoking policies in the

Acknowledgements

The authors would like to thank Margaret Black, Sue Gregory, the two anonymous referees and the senior editor for medical sociology, for comments on an earlier version of the paper.

This research was undertaken with funding from the Chief Scientist's Office of the Scottish Office (Grant No.: K/OPR/17/2). The ideas and views expressed in the article are those of the authors and are not necessarily those of the funding body.

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