Scholarly article on topic '“It is just not part of the culture here”: Young adults' photo-narratives about smoking, quitting, and healthy lifestyles in Vancouver, Canada'

“It is just not part of the culture here”: Young adults' photo-narratives about smoking, quitting, and healthy lifestyles in Vancouver, Canada Academic research paper on "Sociology"

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Abstract of research paper on Sociology, author of scientific article — Rebecca J. Haines-Saah, John L. Oliffe, Cameron F. White, Joan L. Bottorff

Abstract In this article we consider young adults' photo-narratives about smoking and quitting and their linkages to themes of healthy lifestyles and the culture of place in Vancouver, Canada. Drawing from a pilot study using participant-driven photography with a group of twelve young women and men ages nineteen to twenty-six, participants' visual and narrative representations of being a smoker and the process of quitting smoking were analyzed. Findings suggest “healthy lifestyle” imperatives within the Vancouver context may be productive for facilitating cessation, but may also have exclusionary effects.

Academic research paper on topic "“It is just not part of the culture here”: Young adults' photo-narratives about smoking, quitting, and healthy lifestyles in Vancouver, Canada"

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Health & Place

journal homepage: www.elsevier.com/locate/healthplace

Health & Place

"It is just not part of the culture here": Young adults' photo-narratives »p about smoking, quitting, and healthy lifestyles in Vancouver, Canada

Rebecca J. Haines-Saah a,n, John L. Oliffea, Cameron F. White a, Joan L. Bottorffb

a School of Nursing, University of British Columbia, 302-6190 Agronomy Road, Vancouver, British Columbia, Canada V6T 1Z3

b Institute for Healthy Living and Chronic Disease Prevention, University of British Columbia Okanagan Campus, 3333 University Way, Kelowna, British Columbia, Canada V1V 1V7

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ARTICLE INFO

Article history: Received 14 May 2012 Received in revised form 31 January 2013 Accepted 5 February 2013 Available online 28 February 2013

Keywords:

Tobacco

Cessation

Young adults

Collective lifestyles

Participant-driven photography

Visual methods

ABSTRACT

In this article we consider young adults' photo-narratives about smoking and quitting and their linkages to themes of healthy lifestyles and the culture of place in Vancouver, Canada. Drawing from a pilot study using participant-driven photography with a group of twelve young women and men ages nineteen to twenty-six, participants' visual and narrative representations of being a smoker and the process of quitting smoking were analyzed. Findings suggest ''healthy lifestyle'' imperatives within the Vancouver context may be productive for facilitating cessation, but may also have exclusionary effects.

© 2013 Elsevier Ltd. All rights reserved.

1. Introduction

In Canada, national survey data indicates that tobacco use has seen an overall decline in the past decade, yet the 20-24 age group continues to have the highest number of current smokers with rates at 24% for males and 20% for females (Health Canada, 2010). The early adult years are a critical period for tobacco interventions as this is when many non-daily smokers are most likely to establish habitual use (Lantz, 2003). Compounding the problem is that young adults are under-served by prevention and cessation programming, hold negative perceptions of interventions, and are resistant to accessing formal supports for quitting (Hammond, 2005; Bader et al., 2007; Solberg et al., 2007). Yet compared to the literature on adolescent smoking, qualitative research specific to tobacco use during young adulthood has been quite sparse. To address this knowledge gap we undertook a pilot study in Vancouver, Canada that employed participant-driven photography to access young adults' experiences of quitting tobacco. The findings from the photo narratives speak to the significance of health lifestyles and place, in particular how participant's perceptions of a localized discourse on ''healthy living'' in Vancouver has influenced their experience of being a smoker and their attempts at cessation.

* Corresponding author. Tel.: +1 604 822 0545; fax: +1 604 822 7689. E-mail addresses: rebecca.haines-saah@nursing.ubc.ca (R.J. Haines-Saah), john.oliffe@nursing.ubc.ca (J.L. Oliffe), cameron.white@nursing.ubc.ca (C.F. White), joan.bottorff@ubc.ca (J.L. Bottorff).

1353-8292/$-see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016lj.healthplace.2013.02.004

1.1. Vancouver and the culture of healthy living

Vancouver, a city located in the south-western corner of Canada, has been very successful in promoting itself as a place with a healthy lifestyle. ''Health'', in the case of Vancouver, the city, proper, and also its neighbouring municipalities within the Metro Vancouver Regional District, is defined in terms of a lifestyle oriented to access to the natural environment (ocean, mountains and forests), outdoor activities, and sport. This emphasis on healthy lifestyles is a key factor in ranking Vancouver as one of the world's ''Most Liveable'' cities (Economist Intelligence Unit (EIU), 2011) and one of Canada's ''Healthiest Cities,'' with low rates of obesity and high rates of physical activity (Johnson, 2009). As Tourism BC (British Columbia) promotes it, the coastal City of Vancouver combines the ''sophisticated amenities of a world class city'' with nearby access to outdoor adventure such as snow-boarding, kayaking, hiking (Tourism, 2011). Indeed, Tourism BC's website urges visitors to the City partake of what they term the ''West Coast Special''—skiing in the morning and sailing in the afternoon (Tourism, 2011).1

1 B.C.'s ''west coast lifestyle'' is described as being ''based in large part upon outdoor activities, includes such activities as running for exercise, commuting to work by bicycle, kayaking in the nearby waterways, hiking in the surrounding mountain ranges, skiing in the mountains at Cypress and Whistler, taking yoga classes, visiting spas, hitting the links and playing organized sports like baseball or soccer.'' (Veenstra 2007, p. 29).

Alongside the emphasis on healthy living has been the implementation of extensive provincial and municipal smoking restrictions. In addition to Provincial bylaws in British Columbia forbidding indoor smoking in establishments such as restaurants and bars, the City of Vancouver has banned smoking on outdoor restaurant and bar patios, and as of September 2010, smoking was also prohibited in over 200 outdoor public places, including parks, beaches, golf courses and playgrounds (Vancouver Park Board,

2010).2 As noted by Collins and Procter (2011), in addition to providing protections from exposures to environmental tobacco smoke, such spatial restrictions are significant for denormalizing tobacco use as they tend to "push" smokers into less desirable public spaces and send ''a further message about smoking's declining social status" (p. 922).

Yet it is significant that not everyone in Vancouver is equally empowered by the city's options for healthy living, as low rates of smoking and high rates of ''livability'' are accompanied by poor housing affordability (Mertl, 2012), a provincial minimum wage that until 2012 was the lowest in Canada (CBC News, 2012), and the country's highest rates of poverty and child poverty (Ivanova,

2011). The notion of Vancouver as the ''most liveable" city is further challenged when considering the city's Downtown Eastside (DTES), ''a community known for the largest and most heavily concentrated open illicit drug use scene in North America'' (Shannon et al., 2008a, p. 912).The compounded effects of structural inequities and interlinked conditions of homelessness, a street-based survival sex trade, and high rates of substance use in the DTES neighbourhood have been well-documented (Shannon et al., 2008a, 2008b; Bungay et al., 2012).

1.2. Smoking, place, and collective lifestyles

There is long-standing evidence to suggest the importance of area-effects for understanding tobacco use (Stead et al., 2001). As described in a review paper by Pearce et al. (2012) when examining the relationships between place and smoking the research has focused variously on how smoking is influenced by social capital (as place-based features of communities or neighbourhoods), or social practices (shared social norms or culture), can operate as social contagion (networks of peers and contacts that ''spread'' smoking), or as a response to social stress at the neighbourhood-level (relationship between crime, disorder and stress). Social or group-level pathways to cessation have also been studied in terms of place-based regulations, especially smoking bans and smoke-free legislation in public and private places, and local constraints on tobacco retailing, availability and advertising. In their review of socio-spatial perspectives on smoking and tobacco control, Collins and Procter (2011) assert that we need to consider the interplay between social norms and spatial rules (policy restrictions) on tobacco use, particularly as people who smoke may accept or reject such formal restrictions on their smoking (i.e. that the existence of rules and norms does not dictate compliance).

2 In Canada restrictions on public smoking are mandated by the Federal Tobacco Act which forbids smoking in Federal buildings and sites. The Province of British Columbia Tobacco Control Act bans smoking: in any fully or substantially enclosed public place or workplace, within 3 m of most public or workplace doorways, in transit shelters, in the common areas of shared dwellings, on all public and private K-12 school grounds, and in motor vehicles when youth under 16 years of age are present (British Columbia Ministry of Health, 2012). As of 2012, the regional district of Metro Vancouver (comprising 22 municipalities including the City of Vancouver) also banned smoking in regional parks and greenways (Metro Vancouver, 2012). The City of Vancouver has a comparatively lower rate (12.3%) of smoking compared to other regions of the province such as the Interior or Northern regions, where smoking prevalence is 17.0% and 22.8%, respectively (BCStats, 2009).

Poland's work (2000) was perhaps the first to employ qualitative methods to consider how power relations have influenced the shifting social acceptability of smoking and social interactions around tobacco use within public places. His work was critical for showing that beyond adhering to formal restrictions people who smoke enact a discourse of consideration for non-smokers as a strategy for sociability and inclusion when smoking in shared spaces. Since then, other critical scholarship exploring the shifting social geographies of smoking has highlighted how tobacco control's emphasis on public smoking restrictions has had uneven effects across places and population groups. Thompson et al. (2007) have suggested the concept of ''smoking islands'' to describe the persistence of smoking within socioeconomically disadvantaged contexts where people are subject to ''dual stig-matization" (i.e. of being a smoker, of living in poverty). In the context of their qualitative research in New Zealand, they illustrate how tobacco control can inadvertently reinforce smoking, creating pockets of resistance where people frame their smoking as countering the moral emphasis on being ''healthy'' and the stigma they perceived in anti-smoking restrictions. In this case, it is clear that in certain socio-spatial contexts tobacco control may have the unintended effect of creating a context where ''smoking is more accepted, either because of an active sense of resistance on the part of disadvantaged smokers, or a sense of helplessness in their inability to quit" (Bell et al., 2010, p. 797).

In seeking to examine how discourses on healthy living influence the experience of being a smoker and attempts at cessation among young adults living, working and/or attending school in the City Vancouver, this article draws on the work of those who have emphasized the importance of social context and power relations in tobacco research (Poland et al., 2006; Frohlich et al., 2010, 2012). Critical public heath scholars have long problematized the definition of health as a lifestyle ''choice,'' highlighting how structural inequality delimits choice, the moral economy of health behaviours, and the socially constructed imperative of individual responsibility for engaging in healthy lifestyles (e.g., Lupton, 1995; Petersen and Lupton, 1996; Nettleton, 1997). In the context of tobacco control, positioning smoking as a lifestyle choice is premised upon the capacity of individuals to engage in self-motivated behavioural change and therefore defines the inability (or unwillingness) to quit as incapacity or resistance to caring for oneself.

A useful approach to theorizing how young adults' experiences of smoking and quitting tobacco may be shaped by healthy living imperatives within Vancouver, is provided by the heuristic of collective lifestyles as developed by Frohlich and colleagues (Frohlich and Potvin, 1999; Frohlich et al., 2001). As a response to social epidemiology's emphasis on ''disease contexts,'' collective lifestyles are defined as not solely the individual behaviours that affect disease status, but as a collective attribute to reflect the relationship between people's social conditions and their practices. As such, the notion of collective lifestyles offers an analytical tool to unpack how smoking is a practice embedded in place, and to consider how aspects of the local contexts may deter or facilitate tobacco use. This entails a recursive relationship between social location and practice, wherein health behaviours are shaped - rather than dictated by - sets of localized practices. Drawing from Giddens (1984), Frohlich and colleagues have argued for consideration of how smoking is practiced within different socio-spatial contexts in terms of the ''rules and resources people draw on to smoke, or not, and the ways in which people through their practices reinforce these rules and resources'' including, ''the places in which people smoke, who is smoking together, and how smoking is perceived" (2001, p. 793794). As other structurally-oriented health lifestyle theorists have noted, interventions for smoking cessation have been premised

upon the individualist approach to health promotion and health education, with the stages of change model a prime example of an approach that targets individual-level behaviour change but neglects the influence of socio-structural contexts, and how the interplay between life choices and life chances shapes health outcomes (Cockerham, 2005).

Guided by collective lifestyles, our aim was to explore the socio-spatial context and health culture of Vancouver as depicted by young adults in photo narratives about smoking and quitting, and to consider how they view the collective features of the local context as both mediating and motivating cessation. In doing so, we suggest how smoking and by extension tobacco control, are not neutral fields of practice, but are intrinsically tied to social distinctions between the healthy non-smoker and the unhealthy smoker, wherein smoking is positioned as counter to the dominant health culture or lifestyle, and can be associated with stigma and marginality.

2. Methods

As methods that have become widely used in public health and community-based research (Hergenrather et al., 2009; Catalani and Minkler, 2010, Lal et al., 2012), but less frequently applied to research on substance use such as smoking, variations of participant-driven photography (e.g., photovoice, photo elicita-tion, etc.) are increasingly used to access young peoples' perspectives on the relationship between health and social/physical environments (Dennis et al., 2009; Ho et al., 2011). Photo methods are also seen as useful for engaging vulnerable groups such as children and youth in research as they are based on tenets of empowerment and inclusivity (Strack et al., 2004; Wang, 2006, Aldridge, 2012). Participant-driven photography is particularly relevant to contemporary youth lifestyles in countries such as Canada, where young people are surrounded by a predominantly visual media culture and have widespread access to digital still and video photography, with almost half (46%) of Canadians of age 18-34 now owning a camera-equipped smartphone device (Ipsos Reid, 2011).

2.1. Study procedures

This pilot study was one of several studies comprising the iTAG (ww.itag.ubc.ca) research project, from a team of investigators focused on prioritizing gender and tobacco interventions across a range of social contexts. Following University ethics approval the study was conducted in 2009 through 2011. Recruitment focused on participants between 19 and 26-years-old who had recently quit smoking. Our past studies have used participant-driven photography to explore the social context of smoking (Haines et al., 2010; Haines and Oliffe, 2012), but until this study we had not focused specifically on smokers who had actively quit. As we were interested in soliciting insights and imagery from young adults who had some recent success with quitting, we initially limited participation to those who had quit within the last 30 days, while recognizing that the nature of cessation can be fluid and that relapse is common. Due to recruitment challenges in finding recent quitters who were willing to participate, we broadened eligibility to include those who had quit within the past 12 months.

We set out to recruit a convenience sample of students with an emphasis on the campus of the university where the study was being conducted. Recruitment posters were placed around the university campus and also at a number of nearby colleges, and the study was advertised on social networking sites. Recruiting young adults - especially young women - who had recently quit

smoking and who were willing to participate in an intensive photo research activity was difficult and took longer than expected. Although inquiries were received from across the city, almost all those recruited (11) were students at the institution where the research was being carried out, likely due to convenience and accessibility.

Following eligibility screening by phone or email, each participant met with the researchers three times. At an initial visit they were briefed on the study's aims and procedures, provided with a disposable camera, and completed a short background survey. In keeping with informed consent procedures, research staff verbally explained the material in the study consent forms and participants had an opportunity to ask questions and receive clarifications about the study before agreeing to participate. Briefing about the ethical considerations and responsibilities involved in taking photographs was also provided as per established best practices in participant-driven photographic research (Wang and Redwood-Jones, 2001). A separate Release of Creative Materials Waiver was signed, where participants were advised of their ownership of the photographs and specified how and where their images could be used by the researchers. Participants were asked to imagine mounting a photograph exhibition entitled ''Smoking & Quitting—My Views,'' and encouraged to depict any aspect of their experiences with tobacco. A second visit followed, to return the camera for film processing.3 At the third visit participants received their photos and were asked to write captions for at least 3-5 images of their choosing. A photo interview was then conducted to review the set of photographs and to allow participants to expand on the content of their photographs and captions.4 In total, 149 images were submitted and 100 captions written. Photo interviews typically lasted between 30 and 45 min. During the interviews participants' smoking history and experiences with cessation were discussed in greater depth.

After the completion of 12 interviews all participants were invited to participate in a focus group. The purpose of the group was to provide participants with an opportunity to view and discuss the collection of images in a group setting, and to provide further clarification on emergent themes. Five people attended the focus group in March, 2011.

2.2. Participants

Six women and 6 men between the ages of 19-26 took part in the study, and the majority (11) were pursuing full-time post-secondary studies at the time of their participation. Nine were living with a partner or roommate and 3 were living with parents/ family. With regards to the significance of place for our analysis, 5 participants were born and raised in Metro Vancouver (2 from the city, proper, and 3 from neighbouring municipalities of New Westminster, White Rock, and North Vancouver), 4 had moved to the City of Vancouver from other regions in Canada to attend school, and 3 were exchange students from other countries. We did not ask participants to rate their socioeconomic status, but in response to question about their sources of income, 7 stated that they were working part-time and 1 was working full-time while attending school, and the remaining 4 listed ''no income'' and received financial support from their parents. In response to

3 There were 5 participants (3 men, 2 women) who attended the first visit and then dropped out of the study without returning the cameras.

4 Participants were advised of their rights as owners of the images produced, that they had the option of omitting or editing their photos, and were able to specify how photos could be shared by researchers (i.e. publications, presentations). Guidelines for participatory photo research detailed by Wang and Redwood-Jones (2001) were followed to ensure participant safety and privacy.

an open-ended question about their backgrounds the majority of participants identified their ethnoracial background as white or Caucasian, and one self-identified as Hispanic.

The length of time participants had smoked varied from 8 months to 9 years, and 50% had smoked from between 2 and 4 years. Participants reported their smoking status at the time of their first interview as Non-smoker (2), Former smoker (4), and Ex-smoker (3) while 3 participants chose the option Other, listing themselves variously as: Recovering smoker, Smoker having success quitting, and In the slow process of quitting. There were shifts in smoking status over the course of the study. At the completion of the study 6 participants stated that they had stayed quit from the time of initial contact, but 4 had returned to actively smoking. The remaining 2 could be classified as ''occasional'' smokers (i.e., ''off and on'' with quitting).

2.3. Analysis

Recordings of the interviews and focus group were transcribed and checked for accuracy. The transcripts, along with the complete set of photographs, captions, and field notes were entered into a qualitative analysis programme to organize and categorize the data. To further our analysis, we drew from the critical theoretical framework for considering the social context of tobacco use suggested by Poland, Frohlich et al. (2006) which prioritizes how power relations, collective consumption, social identities and place shape smoking practices. Initial readings of the photographs and transcriptions led us to generate eight broad codes used as a means to organize and analyze these findings for themes in the photos, captions and narratives (the codes were exhaustive but not mutually exclusive). These codes addressed social and contextual issues including, lifestyles, identities, and place, with the majority of the data coded under these three codes. To capture how participants framed their experiences visa-vis smoking we included codes that addressed addiction and tobacco control. Specific aspects of tobacco use past and present were also coded under, smoking history and quitting process. An additional code, research process covered data related to study feasibility. Critical readings of these coded findings suggested the two substantive themes that we report in this article. The first theme (3.1) examines how participants view the collective lifestyle or health culture within Vancouver as influencing smoking and cessation. Under a second theme, (3.2) we examine a tension within the photo narrative findings in regards to how outdoor spaces and activities were depicted as providing opportunities to smoke, or as providing the motivation to quit.

3. Findings

3.1. The influence of Vancouver's health culture on smoking cessation

The participants in our study made frequent reference to the informal rules about smoking that they viewed as linked to a local health culture. These social norms appeared to reinforce Vancouver's collective lifestyle as one that is experienced or practiced not only as non-smoking, but potentially as anti-smoker. From this lens, quitting smoking was seen by participants as part of adopting a healthier lifestyle and to assimilating to a dominant Vancouver culture. Photo narratives addressing quitting smoking positioned cessation as a way to transform oneself from an unhealthy smoker, to a healthy, active, non-smoker. As described by a 22-year-old man, the active lifestyle prominent in Vancouver equated with smokers being ''shunned,'' making it ''a lot more taboo to smoke here'' (P03: M, 22). This man, who had success

with quitting smoking, took a photo of a fast food chain he used to frequent and linked this to his smoking cessation (Fig. 1).

In addition to his caption, he offered the following elaboration during the photo interview:

Like I smoked for 8 years and I ate (fast food) a lot... But I wanted, I just want to be fit, I want to be healthy... I feel like I've done so much to myselfin the past 8 years, with eating, smoking, drinking, that I, I regret it and now I. just feel like, you know, I want to feel good with myself. I just, I want to be healthy. (P03: M, 22)

Embedded here are suggestions that recovery from an array of bad habits including smoking will flow from a lifestyle makeover of sorts, whereby all things healthy are embraced, not just abstinence from tobacco. Likewise, a 26-year-old woman spoke about the photo she took of her yoga mats which she captioned, ''positive, healthy.''

Yeah, I don't want to kill myself. I guess it might be the yoga photo... I've noticed an ability, more endurance. I can do everything better. Like you notice a big difference, and I do have an active lifestyle which is why I moved here. So biking, hiking, skiing, yoga, so it [smoking] didn't suit me. (P12: F, 26)

Another participant (Fig. 2) staged a photo to represent the linkages for her between quitting smoking and healthier living.

However, not all participants experienced Vancouver's health culture as a positive motivation for cessation. A 22-year-old woman spoke about the potentially exclusionary discourse around needing to participate in a healthy lifestyle:

When I moved here... the first thing I noticed, was how health conscious this city was. And it was a little bit overwhelming. And I felt like that kind of. stepped on my ability to smoke, which was a little bit annoying... and I just kind of felt like it was wrong and I shouldn't be doing it. I tried to hop on the lifestyle of Vancouver, right? Which failed, but still, you can tell. I feel like you can feel it in the city. (P11: F, 22)

This woman explained that moving to Vancouver made her feel embarrassed that she smoked because ''people were always going for runs, and I'm not usually an active person anyway, so then on top of that to be like the loser in the background who's smoking.'' Motivated by a desire to fit in this participant hid her tobacco use for a time, self-labeling as a ''closet smoker.'' At the time of her interview she had quit smoking but highlighted how she has been chastised for smoking when she had smoked openly:

Fig. 1. Participant 3:1 used to eat at McDonalds when I was a smoker, the two remind me of two bad habits I once struggled with. I feel that eating at McDonald's is comparable to smoking; You know that both are not good for you. Unhealthy lifestyle.

Fig. 2. Participant 06: This is a photo of my workout clothes. Ever since quitting smoking I've been exercising more. It makes me feel very healthy and I like that feeling. I've heard people gain weight when they quit so that was one of my fears for quitting. But since I've been exercising more I haven't gained much weight at all.

But here, a lot of like friends of friends, or even just sometimes, strangers, when you're smoking would come up to you and be like you know, ''Smoking kills."...You know, looking back okay, I understand, but then it's just like why is this your business, why do you care? But meanwhile they're you know in their running outfit and jogging past me and being like you know, ''You're doing something wrong!'' So it was just a constant reminder... it was just in your face. They were like, you know, stop it. ''You're making the city look bad'' kind of thing was what I got. (P11: F, 22)

The idea of smoking as an unacceptable or counter-cultural act was also seen in one of the many photos of cigarette butts on the ground, signifying smoking as a dirty and unhealthy practice (Fig. 3).

As the participant who took this photo explained in her photo interview ''this is how I picture smoking in Vancouver, and it's really, really not accepted here .it's just not part of the culture here. It's very, it's pollution, it's gross, it's lowly... .which is what kind of I guess in the end made me choose to stop'' (P12: F, 26).

Several participants produced images and captions that addressed smokers as social outsiders and highlighted their discomfort smoking in public spaces. Photographs of smoking restriction signs were one obvious way for participants to illustrate some of tensions related to being a smoker in Vancouver. In her caption for a photograph of her standing alone facing a ''No Smoking'' sign, a 21-year-old woman noted how she became increasingly aware of anti-tobacco signage once she quit, writing that, ''As a smoker, 'no-smoking' signs seem to [be] like a double trap: you are trapped into this smoking world, but also trapped out of everyday society into your smoking corner.'' (P11: F, 22). The hyper-visibility of smokers by virtue of their separation and congregation in designated outdoor spaces was also noticed by a female student on an exchange from another country, where she described fewer restrictions on smoking compared to Canada. She remarked on this contextual difference in her photo and caption (Fig. 4).

Other participants who were new to living in Vancouver remarked on how tobacco use was comparatively more stigmatized than other places they had lived. The participant who took the image in Fig. 4 explained that during an orientation for incoming exchange students, a university representative highlighted smoking restrictions in Vancouver and warned students that ''if they catch you smoking, or like near children, like you'll get picked up by the police'' (P10: F, 23). A male student remarked on how smoking was differentiated socially in Canada compared to his country of origin and observed that

Fig. 3. Participant 12: Trashy, especially in Vancouver.

Fig. 4. Participant 10: With this I just wanted to exemplify how society in Canada is very exclusive when it comes to smokers.

tobacco use was more common among the ''international students'' at his university (i.e. those who had moved to Canada to study).

It was notable that participants observed that smokers appeared to be scarcer in number in Vancouver, especially on their university campus. One man linked tobacco use and post-secondary education in a caption accompanying his self-portrait. In a photo where he struck a somewhat defiant or cool pose, with a lit cigarette dangling from the corner of his mouth he wrote, ''Smoking is pretty cool in some social circles, especially outside a school setting. Increased education equals less chance of smoking?'' (P07: M, 25). Through his stance and words he positioned himself as a rebel and outsider, as a university student, but also a smoker. Indeed as a self-perceived minority group in the context of their university setting, there was opportunity for increased cohesion among smokers that counters the stigmatization and exclusion invoked by anti-smoking norms. A male participant confirmed the possibility of smoker groups and argued for the potentially productive nature of these social distinctions, ''where that outsider feeling gets you into a different social circle, so like all those outsiders become closer together so there's like a bond developing outside. having your own party outside'' (P05: M, 21).

3.2. Outdoor spaces: smokefree or smoking freely?

While a central feature of Vancouver's healthy lifestyle is an emphasis on the natural outdoors as a space for sport and exercise, participants in our study also photographed outdoor spaces as settings for relaxation and socializing while smoking.

In regards to smoking and cessation, a contradiction was apparent in terms of how participants represented these socio-spatial contexts as a resource for both motivating quitting and for facilitating smoking; images and captions depicted outdoor activities as part of a strategy for quitting, yet also referenced the freedoms and pleasures of smoking outdoors.

Most participants showcased natural B.C. landscapes to depict their socio-spatial context. Included were photos of the mountain ranges, lakes, beaches, forests and other natural outdoor spaces that in many ways define the City of Vancouver and its surrounding areas (Fig. 5).

In some photos, a cigarette was positioned in a way that made it appear inserted against the natural setting, held up in front of the camera by the participant while photographing a natural scene (Fig. 6).

A 25-year old man succinctly stated in the caption for his image of a hand holding a lit cigarette with the smoke drifting into the dense forest, ''Outdoor settings = smoking lots.'' (P07: M, 25). Another man included an image that referenced the enjoyment of a cigarette while sitting in ''the woods'' with a friend, positioning this as a social rather than solitary activity asserting ''smoking is best with good company'' (P02: M, 19). Women participants also echoed this theme of outdoor settings as spaces to enjoy smoking. For example, an image taken at a beach setting in which the participant is looking out over the water while holding up a cigarette as if she just exhaled was accompanied by, the caption, ''A beautiful view and time to contemplate" (P08: F, 22). Taking a picture of a bench in a park setting, another woman (P11) wrote about the experience of smoking transforming her relationship to outdoor spaces, in that as a smoker she was continually in search of places where she was permitted to smoke (Fig. 7).

In addition to images of outdoor settings as places where they smoked were images that depicted participants engaging in outdoor physical activity as resource and motivation for cessation; images that addressed the dichotomy between the outdoors as natural/healthy and smoking as addiction/unhealthy, as linked to Vancouver's collective lifestyle of healthy, active living. A 21-year-old man who had quit smoking took a picture of an ocean

Fig. 7. Participant 11: A bench like this to a smoker (at least to me) would have been prime location to sit, relax and smoke a cigarette. Everything relates to smoking all the time to a smoker.

Fig. 8. Participant 04: Nature shows a separation from humanity and the body which are tied to addiction. The helmet also shows the use of distractions and exercise to achieve this ''enlightenment''.

Fig. 9. Participant 10: With this pic I meant to say that seeing some of my friends quit and I was still smoking I was ''left behind'' and my friends were moving on.

landscape and added the short caption, ''Breathing fresh air in BC'' (P05: M, 21) and also included many outdoor pictures taken along the route for his morning run which he began as a way for him to ''get in shape'' after he quit smoking. Another man wrote about a recent bicycle trip with a friend and how using his bike for exercise was a ''good distraction'' since he quit smoking, a way of helping to deal with post-quitting cravings for nicotine (P04: M, 22) (Fig. 8).

While these visual themes occurred across the set of images and photo interviews, relationships between outdoor physical activity and cessation among our participants were not always straightforward. For example, one man produced images about enjoying smoking while alpine skiing, wherein having a cigarette was positioned as a relaxing thing to do in the context of outdoor exercise, and described the chairlift up the ski mountain was as his ''favourite'' place to smoke. However, this participant also noted that smoking felt incongruous with his participation in high performance skiing - and saw his participation in sport as somewhat of ''an exception'' among smokers - but also linked the health risks he associated with tobacco use to the element of risk-taking in the ''out of bounds'' back country skiing he participated in. Expanding on how both smoking and cessation were linked to his enjoyment of the outdoors he suggested:

'Cause love of the outdoors is kind of a big reason for me to quit smoking. So I was trying to take some nice pictures in the woods while me and my friend were doing some downhill mountain biking. And he was having a cigarette and, you know, normally, if I was still smoking

I would have been having a cigarette. It's really hard not to like smoke a cigarette like when someone is sitting right next to me doing it at a time that would be really nice. Like taking a break from some hard work, biking and what not and then you're sitting down so it's kinda like this contrasts with this, the fact that the outdoors are a big reason why I try not to smoke just like 'cause I like to try and enjoy them more. My lungs are important and this like my friend smoking right next to me is, you know, my love for smoking kinda conflicts with that. (P02: M, 19).

For this participant smoking, biking and skiing were activities that ''went well'' together, and were perhaps a source of bonding with other like-minded friends, although he experienced being physically active outdoors and being a smoker as a source of tension.

By contrast, more typical anti-smoking images and captions about physical activity were seen in images such as Fig. 2. In this case, participants mirrored predominant health promotion and tobacco control discourse that recommends exercise as a quit strategy and remedy for potential post-cessation weight gain. Echoing the idea that becoming a non-smoker is synonymous with adopting a healthy and active lifestyle, another participant (P10: F, 23) linked quitting to social inclusion and to reconnecting with (non-smoking) friends (Fig. 9).

The sense that smokers can be both social insiders and outsiders reflects the conflict young adults' encounter in navigating smoking and quitting within a particular socio-spatial context where to belong is to be active and to enjoy outdoor activities. In light of the fact that smoking restrictions in municipally-regulated outdoor spaces including Vancouver parks and beaches came into effect during the course of our study, participants did not mention these new restrictions, although research from other contexts suggests that such restrictions can have the normative effect of reducing smoking among young adults because there are fewer places to smoke (Klein et al., 2012). Yet even in the absence of smokefree policies, not all young adult smokers in Vancouver take up the discourse that the outdoors is a natural context that might be contaminated by tobacco smoke, as this is also seen as the ''natural'' domain of smokers and as the ideal place to smoke and relax. The idea that smoking can be a practice that is a pleasurable and enjoyed in conjunction with physical activity also runs counter to dominant health promotion narratives that demands ''getting outside and being active.''

4. Discussion

4.1. Contributions and limitations

This study provided a nuanced description of how young adults' representations of smoking and quitting in Vancouver are influenced by the presence of collective lifestyles that emphasize healthy living and preferences for outdoor sport or physical activity. On a theoretical level the findings add to the growing body of knowledge regarding the relationships between socio-spatial context and health, and reinforce the need to consider the complex interactions that shape how persons engage simultaneously in practices deemed as healthful and those seen as health harming. The collective lifestyles framework is valuable to understanding the interplay between Vancouver's localized health culture as it supports cessation, in conjunction with the presence of municipal and provincial restrictions on smoking; in other words, the presence of a mutually reinforcing relationship between smoking bans and the increased social unacceptability of smoking in public places (Collins and Procter, 2011). In a collective lifestyles framework social norms and structures are not distinct but rather

operate in tandem, although it can be argued that where tobacco use is concerned, a lack of resources to support bylaw enforcement means that informal social sanctions - as seen through their interactions with non-smokers, and as self-imposed by smokers themselves - typically carry more weight than the actual ''rule of law'' in terms of ''policing'' public spaces where people smoke (Poland, 2000).

The use of visual methods provided a way to access the meanings young adults attribute to their health behaviours, and prioritize their views of smoking and quitting as practices socially embedded in place. The use of photo narratives provided intimate illustrations of the relationship between agency (individual's smoking as imbued with social meaning, rather than merely addiction), health practices (smoking/cessation, exercize), and social structures (the rules, resources, and social relations that produce Vancouver's healthy lifestyle) are played out (Stead et al., 2001; Poland et al., 2006). This also speaks to the interplay between agency, social practices and structures and variations in terms of how people respond to local context; even in a context where ''healthy living'' is perceived as a the predominant lifestyle imperative, for some young adult smokers being active and being outdoors is perceived not as motivation for cessation, but the ideal context for smoking. The process of having participants take photographs, reflect on their imagery, and write explanatory captions helped to make visible some of the taken for granted features of the local context that shape young adults smoking, as opposed to ''an understanding of lifestyle that views the individual in a sort of behavioural vacuum; outside socio-cultural influences struggling to master her/his vices'' (Frohlich et al., 2001, p. 784).

While the limitations of photo methods for ''giving voice'' to participants have been interrogated elsewhere (Piper and Frankham, 2007), chief among these has been a concern that visual research be interpreted uncritically as essentialized representations of experiences, when images are not situated within a contextual or discursive framework (Becker, 1978; Harrison, 2002). As many articles reporting on photo-based research projects in health promotion and public health report descriptive, qualitative findings or evaluation outcomes and do not make explicit their conceptual frameworks, our application of collective lifestyles is intended to circumvent this problematic but also to render theoretical concepts tangible and accessible through the use of visual health research (Haines-Saah and Oliffe, 2012). We recognize that our use of this concept to unpack findings from a small, pilot study employing photo-based narratives may be perceived as somewhat simplistic or unconventional, but is nonetheless valuable for positioning smoking and quitting as more than just individually-based behaviours or addiction, and for exploring the ''meaning people attach to the experience of place and health-related behaviour'' (Frohlich et al., 2002, p. 1402).

Although the implications of our study may be specific to, and have limited transferability outside of Vancouver, the method of using photo narratives raises previously unexplored themes regarding cessation among younger smokers that need further exploration in the context of a larger study with a diverse sampling of young adults. A key limitation of our convenience sample is that we did not include young adults outside a post-secondary context, wherein both educational aspirations and achievement are likely to have protective effects with regards to the continuation of smoking over the longer term. Moreover, the positioning of smoking was linked to both a healthy and ''upwardly mobile'' lifestyle for our participants, which may not be the case for other young adults. Arguably, motivations for quitting are likely to be quite different among young adults who are outside of the post-secondary context from which our

participants were drawn (i.e. young people from low-income Vancouver neighbourhoods). That is to say, for some young adults a collective lifestyle of healthy living may be inaccessible or simply irrelevant. A larger study of young adult smokers would certainly need to account for locally-driven variations such as youth cultures, and intersections of socioeconomic, racial/ethnic and gender differences that may influence whether or not smoking is perceived as incompatible with young adults' lifestyles and preferences. Finally, to the extent that our participants were students who had recently arrived in Vancouver from other parts of Canada or from other countries, their impressions of the city's predominant lifestyle or culture or context is arguably not as nuanced as that of longer-term or ''native'' residents familiar with the diversity within the city and lifestyle variations within its neighbourhoods and surrounding regions.

4.2. Implications

At the level of interventions, the implications of our findings direct us away from defining smoking cessation as solely a problem of nicotine dependence, and suggest approaches that emphasize how smoking cessation is influenced by socio-spatial context (Collins and Procter, 2011; Pearce et al., 2011). While these findings may not represent the experiences of young adults living in other contexts where the predominant health lifestyle is not one that opposes tobacco, and where municipal and provincial tobacco control measures may be less restrictive, they reinforce the need to attend to context in planning tobacco reduction efforts. To the extent that the health culture of Vancouver can be a positive facilitator of cessation for some young adults, there is a need to develop interventions that address the needs of young adult smokers who may feel disconnected from, or be resistant to a collective lifestyle centring on active, healthy living. Young adults' representations of smoking and quitting also provide support for tobacco programming and prevention that mobilizes the perspectives of people who smoke in ways that are supportive, rather than playing upon the stigma of tobacco use as a practice that marks off people as social outsiders. Although it has been argued that stigma might be a justifiable, effective component of tobacco denormalziation (Bayer, 2008), stigma-based campaigns are not without ethical and health equity implications (Bell et al., 2010), in particular as contemporary anti-smoking imagery tends objectify smokers as ''diseased and dying'' bodies, and frequently play to gendered appearance imperatives (i.e. smoking will make you old, ugly and unattractive to men) when targeting young women (Haines-Saah, 2011). An emphasis on shame or stigma in anti-tobacco messaging also misses key opportunities to reach out to young smokers who may want to quit, in that it neglects how smoking is tied to their sense of community or collective lifestyle. As has been previously cautioned, ''while being cast as an outsider may stimulate behaviour change in order to fit in with dominant conceptions of 'good citizenship', it may equally give rise to active resistance which is not the desired response of anti-smoking campaigns (Thompson et al., 2007, p. 509).

Another key area for consideration is the need to address how young adults experience pleasure from smoking, an issue that mainstream health promotion and tobacco control have typically neglected (Poland et al., 2006). As suggested by the Foucauldian critique of health promotion and the ''new public health'' (Petersen and Lupton, 1996), which is increasingly used to unpack the moral dimensions of contemporary tobacco control (Bell et al., 2009, 2011; Thompson et al., 2007, 2009; Frohlich et al., 2012),smoking prevention is premised upon a neoliberal conceptualization of governmen-tality, wherein subjects engage in ''reflexive self-policing'' (Poland, 2000, p. 1); where ''good citizens'' prise health and social

acceptability over desire and pleasure. Within our study there were young adult smokers who were explicit about their enjoyment of smoking while engaging in outdoor physical activity, and were cognizant of this apparent disjuncture in these practices; who saw their smoking as ''wrong,'' but with awareness of the health effects of tobacco and its potential to diminish their physical stamina not sufficient alone to deter them. While the promotion of physical activity alongside quitting (i.e., to fight cravings, to stave off postcessation weight gain) and advice regarding using exercise and ''getting active'' to facilitate cessation has long been recommended by the self-help literature (Ussher et al., 2012), it has typically been mobilized in ways that assume that people who smoke are also inactive or unhealthy in their other practices.

In terms of interventions at the structural level, it has been suggested by recent empirical work that the creation of smoke-free post-secondary campuses holds potential for changing social norms around smoking for the 20-24 age group in which prevalence remains high. While interviews with (mainly administrative) stakeholders at three case-study Canadian universities indicated support for campus-wide bans that make smoking ''increasingly inconvenient and less socially acceptable'' (Procter-Scherdtel, Collins, 2012, p. 8), again there is a caution to be raised regarding the potential for social exclusion, even within a place-based context which is arguably privileged. In addition to concerns regarding how such policies might influence student enrolment (equity, self-selection), there are potential safety concerns for student smokers living in campus residences who would need to venture to unlit or isolated areas off-campus areas to smoke (Berg et al., 2011; Procter-Scherdtel, Collins, 2012). Also to the extent that in our small sample were smokers who had come to Vancouver to study from other countries, would such a policy mark off so-called non-Canadian, exchange students as social outsiders? This is not to suggest that there would not be benefits to such policies, but to highlight the need to think critically about the effects for different groups. Indeed as ''remedy'' to an individualist behaviour change, or addiction-oriented approach, structural approaches to tobacco control interventions may also have unintended social consequences (Greaves et al., 2006).

5. Conclusion

Above all, our findings suggest that current strategies in health promotion and tobacco control need to consider more carefully the perspectives of young adults who smoke, and highlight the need for strategies that are credible for this particular population. However, our visual findings also suggest that both positive (i.e. empowerment-based) and negative (i.e. stigma-based) tobacco control messages have the potential to alienate young adult smokers. For example, images that emphasize embracing a healthy lifestyle as the antidote to smoking may not resonate with some young adults who cannot access the resources to facilitate their participation in a local culture of healthy living. At the same time, such strategies may also be ineffective for those young smokers who already engage in practices typically seen as health-enhancing (e.g., skiing, yoga), which they may perceive as a potential trade-off against the harms of tobacco use. Using participant-driven photography provides an alternative, authentic visual perspective on smokers' motivations for quitting, and points to the need for creative messaging that taps into the local context and features of the collective culture - rather than lumping all smokers together as unhealthy, or worse potentially stigmatizing them as social outsiders.

Acknowledgments

The pilot study described here is one of several projects that comprise the Investigating Tobacco and Gender project, funded by a New Emerging Team Grant from the Institute for Gender and Health, Canadian Institutes of Health Research (Nominated Principal Investigator, J.L. Bottorff; Grant number: GTA-92065). John L. Oliffe was supported by a Michael Smith Scholar award. Katherine Frohlich provided critical insights at the early stages of this work that guided the development of this manuscript.

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