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Abstract
Background The use of visual methodologies has gained increased prominence among health researchers working with socially marginalised populations, including those studying tobacco and other types of substance use.
Objectives This article draws from two separate studies combining qualitative and photographic methods to illustrate the unique insights that visual research with smokers can generate for tobacco control.
Methods A purposeful selection of photographs and captions produced by research participants in a study with (1) 20 new fathers that smoke and, (2) a study with 21 adolescent girls that smoke are analysed and discussed in detail.
Results Images produced by smokers illustrate the roles of gender and social context in shaping smoking status, as well as the private struggles with tobacco use experienced by smokers in their day-to-day lives and relationships.
Conclusions Photographic methods have the potential to generate information that may assist in developing tobacco control messaging and programming that speaks to smokers' perceptions of their tobacco use.
- Tobacco control research & practice
- visual methodologies
- advocacy
- gender
- social context
- tobacco control imagery
- visual methods
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- Tobacco control research & practice
- visual methodologies
- advocacy
- gender
- social context
- tobacco control imagery
- visual methods
Introduction
Visual imagery of smokers and smoking are ever present in tobacco control. From the advent of anti-smoking and public health poster campaigns in the UK and the USA,1 2 to the graphic warnings on cigarette packaging implemented in countries such as Canada,3 4 images have been integral to strategies for denormalising smoking and demonstrating the health consequences of tobacco use (Johnson et al,38). Considerable attention has also been devoted to eradicating depictions of smoking from advertising and Hollywood films, due chiefly to concerns regarding the relationship between exposure to tobacco imagery on the smoking behaviours of children and adolescents.5–7 In an effort to counter media portrayals of smoking with so-called ‘deglamourisation’ imagery, the visuals used within anti-smoking mass communication campaigns commonly employ graphic images with ‘fear appeal’ when depicting the health effects of tobacco use.8 Yet missing from the visually mediated context of tobacco control are images capable of portraying tobacco use through the eyes of smokers. Privileging the views of smokers can assist in bridging what has been identified as a growing social distance between tobacco control professionals and their clientele.9 For researchers and tobacco control professionals, visual methods can expose gaps in our current understanding of the social and contextual dimensions of smoking, in particular the gendered and relational aspects of tobacco use.
This article provides an introduction to visual methodologies that enable research participants to document and reflect on their experiences of smoking. Using photographs drawn from two recent Canadian studies with smokers, we illustrate how engaging with visual methods can lead to critical reflection about the reasons why people smoke, as well as elucidating context-specific barriers to tobacco reduction or cessation. Selected images from these two photographic research projects are used to illustrate the importance of developing tobacco intervention and prevention strategies that empower rather than stigmatise smokers.
Methods
In recent years, visual methodologies have gained prominence among health researchers working with socially marginalised populations, including those studying tobacco and substance use. Among the most widely used is ‘Photovoice’, a form of participatory action research that uses photography to promote critical reflection and community engagement on health issues.10 Pioneered by American researcher Carolyn Wang, Photovoice draws from documentary photography, community development and social theory, to enable ‘all individuals to be involved in the public health conversation.11’ In Photovoice, participant involvement extends beyond image making, as central components involve participants writing explanatory captions for their images, and a group discussion regarding how photographs will be shared with community stakeholders. Similar photographic research methods include: reflexive photography,12 autodriving or photo elicitation,13 and photo novella,14 which differ mainly in terms of how and when captions or narratives are written for participants' images, and whether photography is used as an individual or community research exercise.15 16 The broad aim of these methods is to challenge traditional models of knowledge production in research17 by putting cameras in the hands of persons whose experiences are typically neglected, enabling them to emerge as ‘experts’ about the social conditions of their lives.18 With the express aim of empowerment, several photographic projects have focused on community development work with women,19–22 or children and youth.23–25 These methods are now more frequently used by social science and health researchers to address experiences of illness and medical care.17 26 To guard against the potential exploitation of images produced by persons who may already be vulnerable or disenfranchised, methods such as Photovoice follow a rigorous set of ethical guidelines27 so that participants understand the risks and responsibilities associated with the production of photographs as tangible, permanent documents.10 Best practice guidelines in photographic methods emphasise principles of informed consent, respect for privacy (for photographers and people they photograph), participants' ownership of their photographs, and their right to dictate if, when and how their images will be used by the researchers.27
The strengths of participant-produced photography lie in its capacity to engage participants, to shift the balance of power in the research process, and its potential to promote reflexivity about social conditions and experiences.28 29 Despite criticisms of early uses of photography for their privileging researchers' unreflexive representations of the ‘other’, visual methods have a longstanding history in the social sciences.30 It has been suggested that there is particular need for visual methods in contemporary addictions research, because participants' photographs can provide compelling findings about the social contexts in which substance use occurs.31 Similarly, as tobacco researchers increasingly acknowledge the need to understand the socially embedded nature of smoking,9 32 33 research that engages participants grounded within the settings where smoking takes place are crucial.
Although the projects discussed below were conducted in different contexts, they are aligned in their goal to document tobacco use through the eyes of people who smoke. Space limitations preclude us sharing more than a small selection of the photographs produced in each study. However, these images illustrate and support arguments for understanding the views and experiences of smokers. By highlighting the methodological approach and aims of what are among the first projects to use participant-produced photography in tobacco research, the goal of this article is to illustrate the insights that visual methods can provide for tobacco control research and practice. Our focus in this article is on methodology and rationale. Readers interested in the empirical findings and theoretical implications of this research are referred to our previous34–37 and forthcoming publications (Johnson39; Oliffe39).
Results
Study A: the social context of men's tobacco use during their partners' pregnancy and the postpartum period
The visual ethnographic study detailed here is drawn from a research program in Vancouver, Canada, investigating gender influences on tobacco use patterns within the social context of couple interactions during pregnancy and post partum.40 In focusing on gender influences, we were interested in the roles and responsibilities of men and women that are acted out and supported in family units, as well as the societal expectations held about the behaviours characteristic of women and men. Drawing from contemporary social theory, we began from a view that gender identities are actively produced and performed, rather than biologically predetermined. From this perspective, people ‘do’ gender within (as well as in opposition to) cultural ideals of masculinity and femininity.41 As a result of earlier findings suggesting that becoming a father disrupted connections between dominant masculine ideals and smoking42 we became interested in the intersections of place, space and gender in shaping the smoking behaviours of men during their partner's pregnancy and in the postpartum period.
The study cohort included 20 new fathers, ranging in age from 22 to 41 years, who smoked during their partner's pregnancy. Participants and their partners represented varying smoking patterns, and the men were selected to maximise sample diversity (eg, non-smokers, ex-smokers, light smokers, heavy smokers). The number of cigarettes smoked per day ranged from one to more than a pack, and at the time of the interviews four men had quit. Almost half the participants (n=9) reported Asian or Middle-Eastern ethnicities and 11 men reported European ethnic origins. The household income of the sample was evenly spread from less than $20 000 a year to over $100 000 a year.
A series of two in-depth, semistructured individual interviews were conducted within the first month post partum. Towards the end of the first interview, the men were offered a disposable camera and asked to imagine that they were contributing photographs to an exhibition titled ‘smoking through the eyes of fathers’. The men were asked to include photographs that represented where they smoked before, during and after their partner's pregnancy and encouraged to include their favourite smoking places. In the second interview participants were asked to discuss and detail each of their photographs as a means to better understand their perspectives about smoking and fatherhood. The men took between 4 and 27 photographs each, and a total of 308 photographs were produced. These images were linked to the corresponding participant interviews and a four-part approach, including preview, review, cross-photo comparison and theorising were completed to inductively derive categories from which the thematic findings were drawn.37 This involved a theoretical framework derived from Connell's43 work on the social construction of masculinities, and Massey's44 writings on space, place and gender. To reach consensus about the themes and theoretical underpinnings, the authors compared their independently derived interpretations and worked together to refine the analyses and distil the findings.37
Some men suggested that planning what photographs to include and the subsequent interview discussions focused on the images facilitated deeper thinking about their smoking. Others experienced the task as daunting and interpreted the places in which they smoked as obvious and uninteresting. In light of cultural ideals that stigmatise tobacco use and the limitations placed on public smoking in the British Columbian context, it was perhaps inevitable that the processes of self-reflection and disclosure about smoking were problematic for some men. The examples that follow illustrate how men compartmentalised their smoking, but were routinely challenged to protect their child from secondhand and thirdhand smoke.
The commitment to ‘passing’45 as non-smokers in the domestic sphere was especially evident at times when men were in direct contact with their child. The potential for contaminating a defenceless newborn with the remnants of tobacco smoke was an issue for which men used various hygiene enhancing strategies to remove any residual toxins or evidence of their smoking. A 31-year-old information technology consultant offered two photographs demonstrating the hygiene tools that he felt compelled to use to ensure the safety of his 2-month-old baby.
F: Mouthwash…Yeah, that's what I do if I'm at home or somewhere else…mostly at home actually because you hold her so close and you're so close to her that if she gets that scent of smoke, if you're just coming from outside I think she'd be affected by it so, you know, wash my hands, use mouthwash, brush my teeth so it's just the whole routine there.
R: Okay, great. Again this one relates specifically to your daughter?
F: Yeah because I didn't do that before…I washed my hands, not ritually, but it was just here and there, but now it's pretty much bang on. That's the soap dispenser, yeah, like I said just coming back, washing my hands, it actually upsets me if there's no soap in the house or if there's no mouthwash, so I do like to keep that quite handy, you know.
Figures 1 and 2 appear rather mundane at first glance, depicting everyday items dedicated to ensuring personal hygiene; however, within gendered ideals, and in light of the participant's accompanying commentary, significant insights were afforded about issues of power and control. The participant was unable to apprehend his smoking despite the dissatisfaction with the smoke residue that was left on his body and clothes. However, he could, with due diligence, camouflage his smoking by controlling the impact on others through using the hygiene enhancing agents available to him. A long social history exists in which personal and domestic hygiene is portrayed as the duty and domain of women, and for which we are told that men typically have little expertise or appreciation.46 On the surface, the participant's narrative suggests otherwise, in that he self-positioned as a man who should and did care about his hygiene, especially within the context of direct fathering. The self-imposed ‘fumigation’ was an attempt to delink his ‘outdoor’ smoking and ‘indoor’ fathering, and the photographs detail the tools central to that transition. Although clearly invested in this cleansing ritual, the restocking of the home hygiene products is implicitly located as the responsibility of his partner.
Study A
Study A
In terms of self-health, men are routinely positioned as risk takers and many commentaries indicate that women (ie, mothers and wives) influence men's health practices.47–49 This was illustrated by a participant's narrative for a photograph he took of his baby sleeping.
Just a little bit of motivation. That was all that one was. A picture of my sleeping baby, I don't want it to be like a not sleeping type thing and my smoking around him could cause the fact that—‘cause actually I do believe my wife was mentioning that she heard somewhere that smoking can help contribute to SIDS, so generally in my thought was I'm not smoking near him so take a picture of him sleeping, all healthy. That's what I am doing.
Following his child's birth this 27-year-old father reduced his smoking form from a pack a day to half a pack a day. Through engaging with the photography and caption writing processes, this participant's perspective offers insights as to how fatherhood began after the baby arrived, and the birth triggered a discordant relationship between his ideals about fathering and longstanding smoking practices. Although this man continued to smoke he was cognisant that smoking near the baby could disrupt the newborn's sleep and, worse still, secondhand smoke might contribute to the infant's death. The participant's spouse is positioned as a primary source of health information to which he responds positively by relocating his smoking. The image and narrative offer assurances that the man is a good father trying to smoke thoughtfully and cut back his consumption. Multiple and perhaps contradictory masculine identities operate here, in that the man is an involved and caring father, yet he is also autonomous, isolated and solitary in his outdoor smoking. An internal stigma is also evident in which a private battle with addiction is taken up and consciously mobilised by the participant to prohibit smoking around the baby. Like many participants this man was motivated to quit by the presence of his child, whereas the negative effect of smoking on his own health has, apparently, not (yet) been compelling enough for him to reduce his smoking.
A 37-year-old father had his spouse take figure 3 from inside their condominium, looking through the glass door to an outdoor balcony where the participant was lighting his cigarette. This man had a 2-year-old child and a new baby, and was confined to a wheelchair.
F: It's just terrible twos, I guess, when you have a beer and a cigarette kind of deal with me. … It sucks sitting outside, especially in that little hole, because of the bed, the bed is in the way.
R: Okay so this is a smoking place that sort of disappeared for you?
F: Yeah
R: So how do you feel about it being gone now?
F: I just found another place that's all.
R: So are you bothered by like going outside?
F: Yeah you know, you've got to put a jacket on or whatever and dealing with tenants or whatever right, because you're sitting right out there and they all bug me too.
R: Oh really…what type of things do they say to you?
F: ‘Oh you're still smoking’ or they tell me, ‘I quit smoking 30 years ago’…you know the old smoking stories right? …It's okay to hear it, like I know I want to quit, [pause], but I don't know, I guess more feedback. I guess I don't know, it may make me want to quit.
Study A
Figure 3 revealed the participant's new smoking place, and the convenience of the balcony afforded a private outside space in which the man could smoke. He was separated from his family but visible to them through the sliding glass door, whereas smoking outside in shared public spaces was routinely contested by others, and unsolicited commentaries from passers by and neighbours affirmed their judgements and the stigma around smoking. For this man, the idealised combination of beer and cigarettes were dislocated because the two could only be consumed outdoors, which he experienced as far less relaxing than partaking while sitting on the couch and watching television. Moreover, in figure 3, the insider–outside boundaries appear blurred, and perhaps contested in that the sliding door is slightly ajar, making possible the entry of smoke to the suite. Apparent in many men's photographs was a diminished availability of domestic and public spaces to smoke, and inherent challenges reconciling being a smoker with contemporary discourses about being a ‘good’ father.
Study B: the roles and functions of tobacco use within young women's everyday lives
Also combining interviews with participant-driven photography, the ‘Smoke, In My Eyes’ project from Toronto, Canada addressed adolescent tobacco use in women through a focus on the roles of gender and social context in shaping smoking status. In this study, Bourdieu's50 theory of gender and symbolic violence was used to explore the construction and presentation of ‘dominant femininities’ in relation to young women's tobacco use. Although the study design was informed by Photovoice, photography was employed as an individual exercise to promote reflection about the everyday locations and relationships where smoking occurred, and how tobacco use was connected to the gendered experience of ‘being a girl’. Young women were recruited via a research flyer that was distributed in public places across the city of Toronto. At the time of their participation, the average number of cigarettes smoked per day was 12 and the range was from a single cigarette to a package of 25. Most participants had been smoking for at least 2 years, and only three had smoked for less that a year.
In all, 25 young women aged 16 to 19 were interviewed and 21 of these participants contributed photographs. Following an in-depth interview about their experiences with tobacco, young women were invited to take pictures that explored how smoking ‘fitted’ within their everyday lives. Using inexpensive digital cameras, participants produced a total of 211 images and 119 captions. On average, participants returned with their cameras within 2 weeks following the interview, at which time photographs were discussed and captions were written for images of their choosing. The complete set of photographs was initially subjected to a content analysis for visual themes and symbolism. All images (with and without captions) and interviews were then analysed according to a coding schemata derived from the projects' Bourdieusian theoretical framework, with particular emphasis on gender and social context. For a detailed discussion of coding and analysis procedures, and the linking of visual and narrative analysis in this research, see Haines.34
Through their photographs and accompanying text, young women addressed the roles and functions of smoking within a range of contexts and relationships. To illustrate the value added to tobacco control by using photographic research, the images for this paper were selected to address themes of addiction, dependency and cessation, as seen through the eyes of young women that smoke. The researchers' readings or interpretations of the images and their potential significance for informing the design of smoking prevention or cessation programs for young women are also discussed.
Themes related to tobacco addiction occurred several times across the photographic findings. For example, a 19-year-old who had been smoking for less than a year produced an image and caption, framing tobacco addiction as a loss of control. Her photograph showed a young women biting down on a pack of cigarettes that she was holding up to her mouth. She also held a lit cigarette between her fingers, and had a serious, almost angry expression on her face.
This photo makes me laugh because it shows how disgusting the habit of smoking is. (NAME) looks like she is angry that she has the smoke in her mouth and that is the sentiment that I find in a lot of people that are addicted to smoking. Trying to have control over something that she has no control over.
A literal interpretation of this photograph reveals a person consuming cigarettes, yet also presented is the metaphor of being consumed by tobacco addiction. As the photographer explains in her caption, she views her friend's addiction as comic and tragic, with the smoker as a source of humour and disgust. Looking further, an apparent disjuncture between the mocking or playful content of the image and the serious tone of the accompanying text offers another possible layer of interpretation, because this participant may have felt compelled to reproduce socially desirable responses about tobacco as ‘disgusting’. There were other examples in this study where subjects were photographed appearing to take pleasure from their smoking (ie, smiling, laughing) but the caption was about tobacco as unattractive or unhealthy. This contrast between visual and textual content suggests that adolescent participants may well have absorbed the denormalisation of tobacco and the social stigma attached to smokers,51 making it difficult to openly reflect on the reasons why they smoke beyond prevailing discourses of addiction. This image can also be interpreted in the context of the cultural imagery on women's smoking, which positions cigarette use as an unattractive and unfeminine practice (or, paradoxically, as one that suggests women are more sexually available/promiscuous), that contradicts gendered norms regarding appropriate public behaviour.52 Hence by offering up an image of what appears to be an addicted, angry and, perhaps, defiant smoker, the photographer and her subject might be unconsciously signalling resistance to dominant representations of smoking, portraying a so-called ‘bad girl’ identity. These readings of the visual and text point to the complex relationship young women have with their tobacco use, and suggest the need for other messaging than that which positions smokers as powerless in the face of addiction.35
Although several participants highlighted themes of addiction and loss of control associated with cigarettes, the majority of images addressed social dimensions of tobacco use. In comparison to adults, research has emphasised adolescent smoking as primarily socially motivated, with a focus on the roles played by peer networks, group identities and social representations of tobacco in shaping smoking status. However, many of the images produced by participants extended beyond peer-based influences, providing social explanations for smoking. In figure 4, an 18-year-old who had smoked since the age of 14 unpacked her ‘social dependency’ on tobacco.
This is a classic shot of the contents of my bag. I always have cigarettes on me. Ever since that day when trusty (STORE) sold me a pack of cigarettes, I have yet to be without some. They are like a security blanket or something—I don't feel safe going places without them. Furthermore, I know that no matter what if I have cigarettes I can't have a terrible day. Having cigarettes has almost become a defining part of my social life it's like “(NAME), she smokes”, all my friends, family, and acquaintances know I smoke.
Study B
In this image there is a clear theme of cigarettes as an enduring fashion accessory and identity marker for young women.53 Just as carrying a purse can signify a distinctly gendered transition from childhood to becoming an adult woman, it appeared that smoking was conceived by the photographer as a practice denoting a ‘grown up’ social identity. Taken on its own, figure 4 also captures ‘the when and where’ of smoking as ritualistically tied to this young woman's daily routines. Yet the captioning further expands on ‘the why’ of her smoking, as a practice that benefits her at the personal (ie, comfort, security) and peer levels (ie, status, recognition). This suggests that smoking is not just a social practice ‘put on’ when in the company of others, but may also serve as a means for young women to manage emotions, social image and relationships. Previous qualitative accounts have highlighted these competing functions of tobacco use, wherein cigarettes provide comfort and become ‘something you can count on’ during times of stress or difficulty,54 but also function as a way to maintain one's ‘top girl’ status in adolescent social hierarchies.55 With smoking depicted as providing individual and social benefits, the onus is on smoking prevention efforts to give greater consideration to the context-bound nature of addiction and dependency, and to understand how young women perceive the beneficial or pleasurable aspects of their tobacco use.56
Another way that participant photography can be valuable to tobacco research is by providing a view of the private worlds of participants that may be difficult to access during a narrative interview. When research participants take pictures they often document important details that a researcher may not think to ask about, and are also able to share experiences that may be difficult for them to express in words alone. In figure 5, an 18-year-old who had smoked regularly for more than 5 years provided a glimpse of tobacco use within the context of her family home.
This picture was supposed to be of my dad who quit after 30 years of smoking. Supposably outing his last cigarette ever. This was taken in my brother's room where no one's allowed to smoke cause he is not a smoker.
Study B
In addition to a depiction of her father's struggles with cessation, this image portrays tobacco use as a generational practice that occurs within and across families. Parallel to images from Study A, there are competing discourses of child health, parental responsibility and addiction seen in this young woman's representation of her father's long-term use of cigarettes. Although family dynamics may not allow her to directly challenge her father's smoking, through her caption this participant may be expressing scepticism that he will quit smoking. In this study there were other instances where photographs illustrated the social context of tobacco use, interwoven with participants' views about cessation and the health effects of smoking. For example, several young women produced images and captions addressing issues that did not arise during the interviews, such as concerns about exposing younger siblings and non-smoking friends to secondhand smoke, and barriers to cessation including domestic, work and financial stressors. Through elucidating such contextual factors that are ‘known’ but not typically ‘seen’, visual methods provide grounded understandings as to why young women start and continue smoking, beyond issues of addiction or peer-based pressures to smoke. Ultimately, images such as these may point to what is often missing from contemporary youth smoking prevention campaigns, as messaging that targets individual smokers can neglect the social embeddedness of smoking within young peoples' families and relationships.
Discussion
The studies discussed in this article provide examples of participant-produced photographs that hold the potential to create a context of empathy for viewers, as they speak to the experiences of being a smoker in authentic and homespun ways. The photographs also illustrate the interconnectedness of smoking and gender identities within the context of family, partner and peer relationships. In addition to mobilising reflection about smoking practices, there is an opportunity for photographic methods to inform the design and implementation of innovative and participatory tobacco programming, using approaches that are context specific and gender sensitive.
Understanding that gender identities are socially constructed and relationally situated, it follows that tobacco users may have unique ‘insider’ knowledge, as well as the empathy and language to support the smoking cessation efforts of their smoking peers. Mobilising fathers' views about smoking can counter the rhetoric in men's health research, wherein masculinity is routinely situated as a pathologised identity in terms of health risk taking.57 Similarly, dominant cultural representations position women's smoking as a means to contest the passivity and compliance of a ‘good girl’ feminine identity.52 53 The photographs and narratives shared in this article can prompt us to think creatively about how gender roles, identities and relations might work for, rather than against, fathers and adolescent women who smoke. It may be that peer affirmations and permissions afford new ‘smoke free’ identities constructed around alternate versions of masculinity and femininity. Accessing smokers' representations of gender may also provide an opportunity to dismantle the gender stereotyping routinely used by ‘big tobacco’, through delinking representations of smoking with an idealised image of the masculine and feminine. Even as they may be constrained by a dominant social discourse surrounding gender, tobacco and health, the visual testimonials in these studies address the complicated and ambivalent views about cessation held by men and women that smoke, as opposed to the professionally produced images and messaging that is put forward with the sole intent of changing smoking practices.
Whereas it has been suggested that photographs provide insights regarding smoking cessation as more than an individual endeavour and highlight smokers' social connectedness with others, a plausible next step would be the development of photographic research that explores smoking within the context of family and intimate partner relationships. As such, there may be possibilities to develop place-specific research projects that facilitate dialogue and exchange about tobacco use in the context of close relationships and shared living spaces. For example, other visual researchers have documented how photographic research can spontaneously transform from an individual exercise to collective research activity, when participants' family members and significant others assist them with taking pictures, serve as photo subjects and view images together.23 26 In this sense, photography might also motivate the smoker to see their tobacco use through the eyes of others, where open discussions about smoking might be otherwise constrained by gender and relationship dynamics. In the domestic or family context, photography with smokers could also produce valuable insights for policymakers, through documenting unforeseen barriers to implementing and enforcing smoking bans, as well as the unintended social consequences for individuals and their families when smoking is restricted in private and public places. In this way, image-based research can provoke the revelatory “uh huh” factor' for decision makers, as photographs have the capacity to evoke visceral and emotional responses, beyond a distanced, academic understanding of health and substance use issues.31 That said, we do not wish to misrepresent the significance of our findings. Nor should it be inferred that all of the photographs produced in these studies were equally compelling. Indeed the images chosen for inclusion in this article were strategically aligned with the goals of (1) providing an introductory overview to photographic research and (2) highlighting specific findings regarding gender and the social context of tobacco use most relevant to tobacco control research, practice and prevention programming.
Last but not least, we wish to underscore the fact that visual methods are inescapably socially located and subject to the same issues of self-censure, discursive framing and so forth that shape other (especially qualitative) methods. It is true that with images there is a possibility for increased reflexivity and decreased social distance for producers and viewers of photographs. Indeed, the visual may encourage reflection on the social dimensions of smoking beyond the stigma of addiction. But it should also be recognised that participants may be limited by the prevailing cultural denormalisation of tobacco and may not share with (health) researchers the full range of their experiences with smoking. Therefore, when disseminating visual research to a broader audience, it should be made clear that while images can provide powerful insights and a virtual window into the world of participants, photographs do not represent ‘truths’ about people's lives.31 Visual data represent a temporally constructed reality and there are a range of contextual (and discursive) issues that can inform how photographs are composed and interpreted.30 58 59 Indeed, while we have provided coconstructed interpretations of these images and captions, we acknowledge and welcome the fact that other viewers may read these data differently based on their point of view and experience.
Conclusions
In the field of tobacco control research and practice persons that smoke are typically absent from most professional forums, and yet paradoxically, imagery of smokers and smoking is omnipresent. For example, when attending academic conferences or presentations sometimes the only time a smoker is ‘seen’ may be in the image of a disembodied mouth or hand holding a cigarette as shown in slide presentations or prevention materials. In this article we have argued that visual methodologies have promise in terms of bringing the social context of smoking to the forefront, for challenging the desired associations promulgated by big tobacco or by tobacco control practitioners, or (in the case of Photovoice and other participant-generated images) for allowing those working in the field to see through the eyes of the smoker. Photographs can reveal the gap between ‘what we see and what we know’, and show aspects of experience not easily captured through words alone.31 Perhaps most crucially, participant-produced photographs are a stark reminder of the subjectivity and humanity of the other, beyond frequently seen representations of smokers as diseased, dying or disempowered because of their tobacco use. While visually-based strategies such as posters and graphic cigarette package warnings may be an important component of cessation, in current tobacco control the possibility of seeing through the eyes of the smoker is another ‘missing’ piece of the picture that will enable us to develop messaging which resonates with people who smoke.
What this paper adds
There is an identified need to promote the inclusion of smokers within the field of tobacco control in order to bridge what is perceived as a growing social distance between ‘the researcher and the researched’, between non-smokers and smokers, and tobacco control professionals and their clientele.
Research that uses photographs can illustrate to those working in the field how smoking is practiced within different relationships and social contexts. For researchers and professionals, visual methods illustrate the gaps in our current understanding of the social and cultural dimensions of smoking, in particular the gendered and relational aspects of tobacco use. For persons that use tobacco, engaging with photography can lead to critical reflection about the reasons why they smoke, as well as elucidating context-specific barriers to tobacco reduction or cessation.
This article also calls for those working within the field of tobacco control to be cautious about our use of images, and to be mindful of possibilities for multiple readings and unintended consequences connected to the visual imagery of smokers employed by contemporary anti-tobacco messaging.
Acknowledgments
We are grateful to the men and young women that participated in and contributed their photographs to the studies discussed in this paper.
References
Footnotes
Funding The projects discussed in this paper were funded by a student research grant from the Canadian Tobacco Control Research Initiative (CTCRI) (RJH, no. 015521) and grant funding from the Canadian Institutes of Health Research (CIHR, Institute of Gender, Sex and Health) (JLB and JLO, no. B05–0296). RJH is supported as a trainee in the Integrated Mentor Program in Addictions Research Training (IMPART) and Psychosocial Oncology Research Training (PORT) program. JLO is supported by investigator awards from the CIHR and the Michael Smith Foundation for Health research.
Competing interests None.
Ethics approval Ethical approval for this research was obtained from the University of British Columbia (study A) and the University of Toronto and the Hospital for Sick Children (study B). All of the images we discuss in this paper are shared with the express consent of our research participants who signed consent and photograph release forms agreeing that their photographs could be used in academic publications. Please note that in order to comply with BMJ Group patient consent policies we could not include images in this manuscript that identify people.
Provenance and peer review Not commissioned; externally peer reviewed.