Sexual and gender minority (SGM) groups experience nicotine and tobacco (NT) related inequities that persist despite reductions in NT use across the general population. Although institutional trust has important implications for how public health policies are received, few studies have explored trust in tobacco control institutions, especially among SGM communities that are not benefitting equitably from existing approaches. Analyzing narrative data from open-ended interviews with 100 young adults in California, USA, who currently or formerly smoked tobacco and identify in ways that classify them as SGM, we interpret participants’ perceptions of tobacco control efforts in relation to characteristics of trustworthy institutions. Our findings suggest that trust in tobacco control institutions may be compromised by some of the tactics used to denormalize NT use, abstinence-only approaches to NT-related messaging and policymaking, and distrust of the broader establishment of which tobacco control is perceived to be a part. Highlighting trust-compromising consequences of some current mainstream approaches to tobacco control, these findings are important to consider in the development of community-informed messaging strategies and policy interventions to address tobacco-related inequities among SGM populations.
Tobacco control efforts, including smoke-free ordinances, tobacco taxes, flavor bans, purchase restrictions, and anti-tobacco messaging, have been successful in reducing the prevalence of nicotine and tobacco (NT) use within the United States and internationally (Peruga et al. 2021). Yet tremendous NT-related inequities remain, indicating that current approaches do not benefit all members of the public fairly, even in contexts like California, USA, where comprehensive approaches to tobacco control are considered quite successful (Roeseler & Burns 2010). This is especially true for sexual and gender minority (SGM) groups, who have among the highest rates of NT use in the USA and are thus considered priority populations for tobacco control (Buchting et al. 2017, Drope et al. 2018, Li et al. 2021). For example, research suggests that SGM young adults are more likely than their cisgender, heterosexual peers to smoke cigarettes, and transgender young adults in the USA have even higher smoking rates than their cisgender sexual minority peers (Vogel et al. 2019). Failure to reliably and comparably include SGM identities in health data collection complicates reviews of intragroup differences (Dermody et al. 2020), although some research suggests that NT use prevalence is especially high among bisexual women, lesbians, and transgender people (Buchting et al. 2017; Budenz et al. 2022; Li et al. 2021).
To better understand these inequities, researchers have examined how individual and structural factors impacting SGM people shape the roles and meanings of NT use in their lives. Resisting and coping with discrimination (Antin et al. 2018, Budenz et al. 2022, McCabe et al. 2017, Sanders et al. 2020b), economic and housing precarity (Gerend et al. 2017, Wheldon & Wiseman 2019), mental health (Drescher et al. 2018, Hinds et al. 2022), industry targeting (Brock 2018, Emory et al. 2019), and subcultural norms and aesthetics (Tinkler 2006, Youatt et al. 2015) have been identified as important factors related to NT inequities in SGM populations. This growing body of research underscores the need for more SGM-inclusive and structurally-competent tobacco control efforts to better address persistent NT-related inequities (Antin et al. 2023, Baskerville et al. 2017, Hinds et al. 2021, McQuoid et al. 2023). A crucial step in this process requires an examination of how tobacco control strategies can lead to unintended consequences for certain groups more than others, and how those consequences might be mitigated (Antin et al. 2015a, Bell et al. 2010, Bell & Dennis 2013, Evans-Polce et al. 2015, Frohlich et al. 2012, Graham 2012, Reuter 2013, Sanders et al. 2020a, 2020b).
Research on trust in public health authorities suggests that institutional trust impacts why and how public health policies – including those related to tobacco control – can promote (or inhibit) health equity (Gille et al. 2015, Kalulu et al. 2023, Rădoi & Lupu 2017). Trust refers to ‘confident positive expectations,’ (Lewicki et al. 1998, p. 439) and generally involves a relationship between a trustor (e.g., SGM young adults), a trustee (e.g., tobacco control), and a context in which trust needs to be negotiated (e.g., NT-related health messaging) (Kramer & Tyler 1995, PytlikZillig & Kimbrough 2016). Five characteristics are generally considered important elements of institutional trustworthiness (Kim 2005): (1) credible commitment, meaning that an institution is perceived as consistently acting in the public’s interest; (2) benevolence involves an institution demonstrating ‘care and concern’ for the relevant public through its actions (Kim 2005, p. 625); (3) honesty is associated with exhibiting integrity and ‘adherence to ethical standards’ such as transparent accountability and doing no harm (Kim 2005, p. 626); (4) competency is demonstrated by strong performance and productivity in an institution’s area of authority; and (5) fairness entails abiding by equitable principles.
These characteristics overlap and, in practice, are often perceived interdependently (Kim 2005). For example, where competency is dependent upon accurately understanding a trustor’s needs, both benevolence (i.e., caring enough about the trustor to be concerned for their needs and make efforts towards understanding) and credible commitment (i.e., being oriented towards and invested in the trustor’s interests) may be required. Fairness, too, may be a relevant characteristic in this example if the trustor perceives that the institution’s benevolence and credible commitment inequitably apply to some publics but not others, such as historically marginalized publics whose needs may not generally be considered or understood by institutional authorities. To the extent that a public regards the policies and practices of an institution as harmful to themselves and their communities, that institution’s perceived trustworthiness may be compromised in that its credible commitment, benevolence, integrity, competency, and fairness are undermined.
Unfortunately, research suggests that this consequence may be especially relevant for SGM communities, who exhibit high rates of distrust in government institutions, especially health institutions (Cahill 2021). Studies suggest that reduced trust in health institutions among stigmatized populations is shaped by the larger context of structural violence to which their communities have been subjected (Jaiswal & Halkitis 2019). Indeed, some research shows that SGM perspectives on tobacco control efforts are inflected by legacies of SGM stigmatization in medical care, governmental policies, and society (Sanders et al. 2020a, 2020b), illustrating how tobacco control approaches positioning NT use as a stigmatized, deviant behavior “intersect with historical constructions of queer bodies as risky, at-risk, and in need of regulation and correction” (Sanders et al. 2020a, pp. 195). Such approaches further stigmatize SGM people who use NT while also ignoring the ways that NT use can be a response to stigmatization in the first place (Antin et al. 2018, Sanders et al. 2020a, 2020b).
Although trust in tobacco control impacts how communities receive and respond to anti-tobacco messaging and policies (Avery 2010, Jarman et al. 2017, Pornpitakpan 2004, Schmidt et al. 2016), few studies have examined trust in relation to tobacco control practices or institutions (for exceptions, see Boynton et al. 2016, Case et al. 2018, Jarman et al. 2017, McCullough et al. 2018, Ranney et al. 2018), particularly among SGM young adults. Identifying ways in which trust in tobacco control institutions may be compromised among populations that are not benefitting equitably from existing tobacco control approaches may reveal insights that have been previously neglected. Doing so may also help to identify ways in which we can envision and implement equitable and effective forms of public health support for these priority populations.
Towards this end, we analyzed narrative data from 100 open-ended interviews with SGM young adults in the San Francisco Bay Area, California, USA, to examine their perceptions of existing tobacco control efforts. Informed by the characteristics of institutional trust outlined above, our interpretations focus specifically on the ways in which participants’ perceptions of tobacco control efforts provide insight into their trust in tobacco control institutions.
This analysis is based on interview data collected between May 2020 and February 2022 from 100 young adults aged 18-25 in the San Francisco Bay Area who use or previously used combustible tobacco (primarily cigarettes), and who identify their genders and sexualities in ways that classify them as SGM. We recruited participants with a breadth of sociodemographic characteristics and experiences relevant to the main study aims of exploring tobacco harm reduction practices and perceptions among young SGM people (see Antin et al. 2023). Likely due to the social gradient in smoking (Graham 2012), participants, on average, experienced multiple disadvantages, including housing insecurity, low socio-economic status, and high levels of interpersonal and structural stigma related to their SGM identities. A description of the sample drawn from this study’s accompanying closed-ended survey is reported in Appendix I.
Participants completed a 30-minute online survey followed by a one-on-one online video interview lasting up to two hours. For a detailed description of the interview guide, see Antin et al. (2023). We recruited participants through online advertisements (Craigslist, Facebook, Instagram), physical flyers, community-based organizations, and by referral (limited in number to reduce bias). Eligible volunteers received a unique link to complete the consent form and survey in advance of the interview. After the interview, participants received a $50 honorarium. All interview audio was professionally transcribed before being reviewed by interviewers for accuracy. Our organization’s Institutional Review Board approved all study procedures.
Thematic analytical methods are well-suited to qualitative health research in that those methods permit participants’ perspectives to be centered while also allowing flexibility in the conceptual frameworks researchers use when crafting their interpretations (Braun & Clarke 2023). We began by coding transcripts using ATLAS.ti. We approach coding as both an interpretive undertaking that informs our preliminary analytical ideas about the data, and as a pragmatic process to index large amounts of qualitative data to facilitate further analyses. During the process of familiarizing ourselves with the data, the research team collaboratively developed a codebook of 38 codes with which to organize the dataset. This included general descriptive codes to index specific sections of the interview (e.g., Nicotine/Tobacco), semantic codes to capture inductive topics grounded in participants’ narratives (e.g., Moderation), and latent codes derived from our analytical framework (e.g., Trust).
Next, the first author reviewed all interview data indexed within the ‘Nicotine/Tobacco’ code that were also coded with ‘Policy,’ ‘Trust’ and/or ‘Information Sources’. Iteratively reading the resultant data, the first author began to identify patterns emergent across narratives (e.g., different people expressing similar sentiments, opposing sentiments, unexpected sentiments, and/or referring to particular tobacco control efforts) (Bernard & Ryan 2009) and to record preliminary analytical interpretations about how these might relate to characteristics of institutional trust (Braun & Clarke 2022). This informed a subsequent text search for salient terms to locate any conceptually relevant data not previously captured and to search for disconfirming narratives that might modify our initial interpretations (Antin et al. 2015b). Any relevant interview data not captured in the initial report was reviewed by the first author and added to the body of data identified for further analysis.
The first author then shifted to theme development (Braun & Clarke 2022, LeCompte & Schensul 1999), paying close attention to what participants’ narratives suggested about their trust assessments of tobacco control institutions. Returning to the characteristics of institutional trust outlined above, we consider the extent to which tobacco control was regarded by participants as (1) consistently acting in the interest of participants and their communities; (2) caring for these communities; (3) operating with integrity, including communicating honestly with these communities; (4) competently engaging with these communities (i.e., meeting their needs); and (5) treating these communities equitably. With these characteristics in mind, we grouped quotations according to similar themes, which we describe in detail below. Longer examples of quotations are reported in Appendix II. Pseudonyms selected by participants are used to attribute quotations.
Our analysis of narratives about tobacco control suggests several interrelated themes with implications for understanding NT-related institutional trust. First, participants described messaging and tactics used in media campaigns as unhelpful, harmful, and at odds with their own experiences, in ways that called into question the benevolence, competency and fairness of these efforts. Second, participants perceived bias introduced by an abstinence approach in tobacco control efforts, which they saw as compromising honest communication and competent policies appropriate for their own health-related concerns. Third, some participants held suspicions that tobacco control and the tobacco industry might be part of the same disingenuous, self-serving establishment that they associate with the perpetuation of health inequities and societal injustices. This perspective led to skepticism and distrust around the credible commitment, benevolence, honest integrity, competent performance, and equitable fairness of tobacco control institutions. Our findings highlight trust-compromising consequences of some current mainstream approaches to tobacco control that may impede advancing health equity for SGM populations in California.
Participants generally spoke about tobacco education and prevention messaging using phrases like ‘out of touch’ (Charlie), ‘ridiculous’ (Moss), ‘so corny and stupid’ (Athena), ‘offensive’ (Lucas), ‘really in your face’ (KJ), ‘intense [...] yikes’ (Wakanda), ‘pretty messed up’ (Taylor), ‘violent [...] triggering’ (Chantal), or ‘heavy-handed and very shaming’ (Bella) to describe their overall perceptions of anti-NT campaigns. While some participants supposed that hard-hitting campaigns might be effective for some people (especially children) and overall implied that NT education efforts have been successful, declaring ‘everyone knows that smoking is bad’ (Bernie), participants largely did not consider the messaging appropriate or helpful in their own lives. Participants explained these critiques in relation to two main issues: 1) the use of stigma, which they found unethical, counterproductive, and harmful; and 2) messages that were at odds with participants’ lived experiences and desired forms of health-related support. This suggests that participants perceive tobacco control messages as being created by authorities who are not invested in (i.e., credibly committed to), benevolently concerned about, nor particularly familiar with (i.e., competent about) their needs and experiences.
For example, Alice (see Quote A, Appendix II) argues that instead of providing nuanced information people can use to make more informed choices about their practices, anti-NT ads often strategically utilize selective information (Kozlowski & Sweanor 2016) delivered in extreme rhetoric to promote abstinence, which may also be perceived as stigmatizing the use of drugs (and by extension, drug users) as ‘bad’ and ‘wrong’ (Bell et al. 2010). Alice clearly does not have ‘confident positive expectations’ that the messages produced by tobacco control institutions will provide relevant information (competency), consider their experiences (credible commitment), nor communicate care and respect (benevolence). Additionally, framings of NT users as ‘dumb’ and ‘wrong’ are not accurate in Alice’s experience and therefore perceived as further out of touch and alienating. This may suggest to participants that tobacco control institutions lack a credible commitment to their interests, do not care about their needs, and portray them unfairly, thereby compromising participants’ trust in these institutions, or at least their messages.
Participants made it very clear that tobacco control efforts have been hugely successful at reducing the social acceptability of NT use and informing the public that it is dangerous. But their narratives further emphasized that because campaigns employ stigma to do so, they also may be harmful to some people who use NT, and counterproductive. Other research suggests this may be especially harmful for SGM people (Sanders et al. 2020a, 2020b). In line with existing research (Bell et al. 2010, Graham 2012, Sanders et al. 2020b, Voigt 2013), participants like Chantal did not think this was particularly ethical, health-promoting, appropriate or ‘helpful’ (see Quote B, Appendix II). This suggests that participants view some tobacco control campaigns as lacking in benevolent ‘care and concern’, competent efficacy, and adherence to equitable principles in tobacco control institutions, which may compromise their trust.
To some participants, the rhetoric used in many anti-NT campaigns also created a troubling sense of ‘us’ versus ‘them’ that is foundational in the othering processes of stigmatization and all-too-familiar to SGM young adults (Link & Phelan 2001). This may create the impression that anti-NT messages (and by extension, the institutions creating those messages) are positioned against SGM people who use NT rather than for them. Answering a question about what could be done better for people who use NT, Rach suggested not ‘creating extremes’ that beget ‘polarization’ and the ‘shunning’ of smokers, which she described as less supportive and effective than providing NT users with nuanced information (see Quote C, Appendix II). From this perspective, and given the concentration of NT use among marginalized groups (Drope et al. 2018), social denormalization efforts may be antithetical to equitable principles important in institutional trust. Another participant, Francis, also brought up fairness in characterizing some anti-NT messages as closer to manipulative ‘propaganda’ than education because she finds them ‘biased’ and the information they convey ‘one-sided’ (see Quote D, Appendix II).
Although existing research has demonstrated similar critiques of denormalization efforts among smokers in general (Bell et al. 2010, Evans-Polce et al. 2015, McCullough et al. 2018, Ritchie et al. 2010, Veldheer et al. 2019) and SGM smokers specifically (Sanders et al. 2020a, 2020b, Hinds et al. 2021), little research has explored how such perspectives may impede the efficacy of existing approaches specifically by contributing to distrust in tobacco control among stigmatized populations. Narratives from our participants suggest that trust in tobacco control may be compromised due to perceptions that tobacco control messaging is ‘emotional[ly] bias[ed]’ (Alice), stigmatizing ‘propaganda’ rather than earnest educational health communication that is tuned-in to SGM young adults’ health needs.
Several of the quotations thus far presented suggest that participants perceived NT prevention campaigns to be exclusively focused on advancing an abstinence-based approach to drugs education and health promotion (see also Antin et al. 2023 for more on how participants’ views of abstinence approaches are inflected by the socio-structural harms to which they are subjected in relation to their positionalities). Furthermore, this abstinence approach was directly cited by some participants as a reason they do not regard tobacco control institutions as a reliable source of information to answer their nuanced questions about how to understand and navigate the risks related to their NT use. For example, as Alice and Francis suggested (see Appendix II, Quotes A & D), to the extent that these ads present information intended to deter rather than simply to educate, they do not meet the needs of people who are already using NT and not necessarily seeking deterrents. When asked how they seek out health information about NT, Alice, for example, explained further that they don’t rely on tobacco prevention websites because of bias created by the abstinence orientation of such sites (see Quote E, Appendix II). Similarly, using the example of hallucinogens, Claude discussed how their own lack of trust in some NT-related public health information sources is informed by the inherent bias they perceive in abstinence-based approaches to drugs more broadly (see Quote F, Appendix II).
For many participants, decisions regarding which sources to trust for information about NT are informed by analogous experiences with other abstinence-based approaches they have encountered. Beyond other drugs, some participants also discussed their experiences with abstinence-based sex education - as insufficient, uninformative, and lacking pragmatism - to explain their distrust of abstinence-based approaches to tobacco use. In other words, participants lack confident positive expectations that abstinence-based approaches to health education will effectively meet their information needs (competency), be responsive to their information-related interests versus the messenger’s own ‘best interest’ (credible commitment, benevolence, fairness), or tell the whole story (honesty). Additionally, insofar as withholding nuanced health information from the public is unethical (Kozlowski & Sweanor 2016), integrity and fairness are also aspects of the trust relationship with tobacco control institutions that may be compromised by abstinence approaches.
Discontent with abstinence approaches also emerged when participants described the vaping and related flavor bans that had recently taken effect in some areas. Some participants described switching back to cigarettes from vaping, with others relying on illicit markets to access vape products, both of which introduced more risk than was the case before the bans. The ways in which these bans were perceived to increase rather than decrease the harms associated with NT use contributed to the belief among some that abstinence-based approaches to policy-making, rather than harm reduction approaches, are headed ‘in the wrong direction’ (Ant). The bans were also experienced as undermining the perceived competency and benevolence of tobacco control institutions as credibly committed to the various publics they serve, particularly to participants’ communities. For example, Ant shared that recent product bans in his area had led some of his friends to switch to smoking after vapes became inaccessible (see Quote G, Appendix II). The NT pathways Ant describes among his friends due to product bans demonstrate a serious unintended consequence of abstinence-oriented tobacco control policies. For Ant, these policies are directly harmful to a community of ‘friends [that] went back to smoking cigarettes,’ and as such may compromise his trust in tobacco control institutions by contributing to the perception that tobacco control institutions are not credibly committed to the interests of his community nor to ensuring their policies have equitable impacts.
Tennis, who prefers vaping over smoking but has turned more often to cigarettes since vapes were banned where he lives, also discussed the underground economy for vapes created by the bans, and how this increases the danger for people who now access vapes from illicit sources (see Quote H, Appendix II). For Tennis, Ant’s friends, and many participants, tobacco control efforts targeting relatively less harmful products like e-cigarettes have increased, rather than decreased, the health risks associated with their NT use. These policies that are described as directly harmful, therefore, lack credibility, competency, and fairness for those participants and their communities, which may ultimately undermine trust in tobacco control.
… it's dumb that these ads are being made while the government still condones it. […I]t's just the establishment kind of gaslighting us and just saying like, "Oh, we're going to provide you with this and really market it to you, just to tell you, 'You're bad for taking it'." … It's paradoxical and hypocritical and ridiculous. (Wakanda, 23 year-old Black nonbinary lesbian)
Participants sometimes offered glimpses into their perceptions about who was behind NT prevention campaigns or other tobacco control efforts. Notably, no participant used the phrase ‘tobacco control’ at any point but, instead, seemed to consider tobacco control as ‘anti-tobacco people’, ‘the government’, and/or ‘the establishment’, which may or may not include a variety of health researchers and practitioners. The complex funding structure and myriad institutions underpinning tobacco control efforts operating at multiple scales may inhibit a sense of transparency and familiarity with tobacco control among the public. Transparency is a critical part of trust relationships, and troublingly, research suggests that a lack of familiarity with agencies responsible for tobacco prevention messaging can contribute to public distrust (Ranney et al. 2018). In short, it was unclear to participants who tobacco control professionals and authorities really were, which often led participants to fill in the blanks, suspicious about unknowns.
Some participants’ criticisms of NT prevention campaigns were justified by disidentification with and/or suspicion towards the entities they imagined to be behind the campaigns. For example, figured in striking similarity to the ‘man behind the curtain’ (Fleming 1939), the entity Tom imagines (see Quote I, Appendix II) is introduced as someone with whom Tom does not identify and who, as an ‘old, white dude’, arguably represents the establishment. Tom posits that this authority figure is either completely out of touch with Tom’s own reality, or worse, maliciously disingenuous and motivated by profit. These two options emerged within other participants’ narratives as well. In line with the first option Tom brings up, many other participants perceived that tobacco control was positioned ‘against’ people like themselves who use NT, as we saw in the first section’s narratives from participants like Rach, Chantal, and Alice.
The second possibility that Tom suspects is that tobacco control campaigns are disingenuously created for the surreptitious purpose of profit, by players who are not actually anti-tobacco. Though not as prominent in the sample overall, this general idea was echoed by several other participants who also expressed a more explicit distrust of some tobacco control efforts they had encountered. For instance, some participants suspected that the tobacco industry was behind at least some of the anti-vaping campaigns they had seen. As Indica said, ‘The tobacco companies are producing a lot of these ads that are against the JUUL1 and against vaping because they're trying to make money and monopolize the market’ (24 year-old trans femme asexual panromantic mixed race participant).
Wisteria also believed that ‘cigarette companies make some of the anti-vaping ads’ (22 year-old bisexual, nonbinary/agender Vietnamese American participant). Likewise, Ant, introduced above, explained ‘A lot of the vaping restrictions was pushed by big tobacco, and it got JUUL in a ton of trouble.’ Additionally, though less convinced than some participants, Ami supposed that ‘Maybe they're trying to get cigarettes back in business, with the vape slander’ (21 year-old mixed race pansexual cisgender woman). While Ant, Indica, and Wisteria’s statements indicate they heard this information somewhere specific, Ami’s more general supposition suggests that messages ‘slandering’ vaping make more sense as a harmful industry trick than a legitimate public health stance, given how antithetical to harm reduction principles it is to be so vehemently against a less harmful alternative to smoking. Regardless of the source, some participants earnestly hold these beliefs as part of the way they view tobacco control efforts. Thus, these perceptions are important to consider in better understanding how they arise and what public health authorities can do to avoid being perceived as sharing the tobacco industry’s interests.
Other participants voiced similar suspicions of greed, corruption, and ulterior motives operating among the entities they understood to be involved in the complex landscape of nicotine and tobacco product regulation in the US. While Tom above focused on an imagined authority figure, other participants’ suspicions of tobacco control efforts were voiced at a more institutional register concerned with the overlapping systems of government, business, and funding structures in the USA. For example, rather than the tobacco industry, CH suspected that the government does not actually want people to quit smoking because of excise tax revenue, and that this motivates tobacco control efforts such as tax increases and the anti-vaping push they help to fund (see Quote J, Appendix II). CH further explained her perception that this increasing ‘regressive’ point-of-sale tax on NT consumers is ‘really harmful’ because ‘it really only punishes people who are already addicted to it and who typically tend to be lower class and ... can't afford that greater cost’. The social gradient in smoking (Graham 2012) is a multi-faceted structural issue. It was also framed by many participants as particularly compelling evidence of unjust and predatory industry malfeasance. However, given this precise situation, CH’s narrative suggests that these kinds of regressive taxes may be a form of government targeting of these same communities that already face structural disadvantages for which the government has not implemented effective solutions. Tobacco control support for these policies may contribute to the perception of tobacco control policies as lacking fairness, benevolence, and a credible commitment to historically marginalized communities’ health.
Valentina expressed a related sentiment by comparing US NT packaging policies to other countries she had visited that require more explicit health warnings, perceiving the reason behind the USA’s relatively uninformative packaging to be, again, government profit and corruption (see Quote K, Appendix II). Tobacco control and the government in general have taken steps towards the kind of packaging changes Valentina is calling for, but these efforts face opposition and legal delays from the industry and its enormous financial resources (Sachs 2023). However, Valentina’s perceptions about the reasons for disparities in packaging requirements being part of a larger issue of governmental authorities prioritizing profit over health are nonetheless quite suggestive of the ways in which trust in one institution can impact other institutions even if they are not directly connected (Benkert et al. 2019). Valentina does not trust the powers that be - including those regulating tobacco in the USA - to ‘care’ about the public’s health needs. She justifies her perspective within the context of inflated prescription drug prices, housing barriers, and food insecurity, which she frames as problems that could be solved if not for the government’s ulterior economic priorities.
Perspectives like those shared by CH and Valentina demonstrate how suspicion towards tobacco control efforts may be related to larger disillusionment and low trust in the structure of government in the USA overall, and the corporate establishment it often supports (Blendon & Benson 2022). In short, many participants invoked evidence of the government prioritizing profit, for itself or its valued corporate citizens, as a more appropriate explanation of poor health in America than individuals’ decisions to use NT.
Many participants did not trust the government to act in the best interest of its people because they witnessed it failing to do so in other contexts and saw no reason why tobacco control would be any different. For example, in answering our question about what society, the government, or public health could do better for people who use NT, Camryn brought up structural failings and weaknesses in US healthcare systems and social welfare programs to contextualize and justify their perception that public health in the United States is undermined by the prioritization of economic profit and politics (see Quote L, Appendix II). This again demonstrates how impacts on trust may have cascading effects across a range of institutions (Benkert et al. 2019) that sometimes operate at cross purposes, limit each other’s reach, have very different histories, and yet may often be perceived as part of the same dominant establishment. This reminds us that trust in tobacco control is intimately tied to a broader structural context related to governance, corporations, and a complex web of public health institutions.
The findings presented suggest that current dominant approaches to tobacco control in California are perceived by some NT-using SGM young adults as insufficient and inappropriate. This may not only render certain efforts less effective at health promotion for this population that faces significant NT-related inequities, but may also compromise their trust in tobacco control institutions in ways that could potentially contribute to these inequities./p>
As the most visible public ‘face’ of tobacco control, messaging campaigns such as TV, print, and radio advertisements may be particularly impactful on public perceptions of this institution. Participants clearly felt that these messages were: 1) not created with their interests in mind; 2) demonstrative of disdain and disregard rather than benevolent ‘care and concern’ for people who use NT (Kim 2005, p. 625); 3) lacking honest integrity given clear bias and withholding of pertinent information (Kozlowski & Sweanor 2016) combined with an unethical reliance on stigma; 4) ineffective or ‘unhelpful’ and therefore lacking competency by being so ‘out of touch’; and 5) unfair to the extent that, in addition to mobilizing stigma against people who are already otherwise stigmatized, they are not designed to support people who are unable or uninterested in quitting NT and who therefore are arguably most in need of public health support. The extent to which participants described messaging campaigns in ways that contrast starkly with the characteristics of trustworthy institutions suggests that these types of messages may not only be ineffective for many SGM young adults who use NT, but also that they may be especially damaging to participants’ trust in tobacco control. Framing tobacco control messaging as prioritizing one perspective while neglecting others like their own, participants perceive that tobacco control messages do not value or account for their feelings, perspectives, and experiences. This suggests that some young queer people who use NT may feel that tobacco control messages are not for them, and, by extension, that neither is tobacco control. This would constitute a fundamental threat to trust in tobacco control that may make tobacco control efforts less effective and potentially iatrogenic for some members of this population.
Other findings focused more specifically on the skepticism with which participants regarded abstinence-oriented approaches to health education and policy, including NT education and prevention, which they characterized as unreliable and insufficient for their needs. Participants explained that they do not rely on information from prevention sources because it advances an abstinence agenda designed explicitly to deter rather than simply educate, which they perceived not only as introducing bias, but as conflicting with their own priorities. Participants also discussed how their lived experiences cast doubt on the comprehensiveness, pragmatic applicability, and effectiveness of abstinence discourse, and how policies that prioritize abstinence goals over harm reduction by making less harmful products harder to access, such as bans on e-cigarettes, exacerbated the NT-related risks participants navigate. Moreover, such perspectives also demonstrate the ways in which an abstinence orientation specifically may erode trust in tobacco control among SGM young adults who use NT by compromising the perceived honesty, competency, and fairness of the information disseminated and policies enacted by tobacco control institutions.
Finally, we found that participants questioned the entities and motives structuring tobacco control efforts in the USA. Their narratives revealed both considerable ambiguity about who is responsible for NT policies and regulations in the USA, as well as suspicion around economic motives that undermine effective health promotion in tobacco control efforts. The latter, which also emerged in McCullough and colleagues’ (2018) research about low-SES smokers’ perceptions of tobacco control campaigns, was strongly inflected by perceptions of corporate and governmental profiteering in the US establishment more broadly. These perspectives suggest that larger institutional failures to adequately or equitably protect consumers and prioritize the public’s health on adjacent issues such as health insurance and medication pricing shape public perception of tobacco control efforts.
Overall our findings raise questions about trust in tobacco control among this priority population that require further research attention. Specific SGM intragroup differences in institutional trust were beyond the scope of the present study but would benefit from future research efforts seeking to support the development of culturally-responsive policies. This lack of trust, if widespread, may make tobacco control efforts less effective at addressing persistent inequities (Annechino & Antin 2019; Antin et al. 2021). Thankfully, however, participant perspectives also highlight the strong potential of harm reduction approaches as a promising ‘path’ towards promoting trust in tobacco control among priority populations like SGM young adults who use NT (Antin et al. 2021). Instead of an abstinence-oriented ‘anti-drug’ agenda, narrative data from this study suggests that participants would see themselves better reflected, considered, and cared for within an agenda structured by the principles of harm reduction, whereby reliable information and accessible resources are provided to help respectfully and equitably support their decision-making (Kozlowski & Sweanor 2016).
Participants’ perceptions examined here underscore ways in which harm reduction approaches may be more appropriate for meeting participants’ needs around health-promotion, more relevant to informing their practices, and also better aligned with their values (which call for pragmatic, person-centered, non-judgmental, and structurally competent approaches to tobacco control (see Antin et al. 2023)). Additional research demonstrating participants’ adoption of tobacco harm reduction practices despite a lack of formal guidance (Antin et al. 2023) and thus considerable confusion about relative risk (Lipperman-Kreda et al. 2024) further illustrates how mainstream approaches to US tobacco control, focused exclusively on deterring use at the expense of providing guidance about reducing harm, may be failing priority populations that experience persistent NT-related inequities.
We deeply appreciate the 100 participants who generously shared their time and perspectives for this study; our work would not be possible without them. This research was supported by funds from the Tobacco-Related Disease Research Program (TRDRP) of the University of California, grant number T30IR0890 (Tamar Antin, Principal Investigator). The content provided here is solely the responsibility of the authors and does not necessarily reflect the opinions of TRDRP. The authors declare they have no conflicts of interest.
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