An Exploration of Rural Housing Insecurity as a Public Health Problem in California's Rural Northern Counties.

Although widely acknowledged as an important social determinant of health, until recently researchers and policymakers have primarily approached housing insecurity as an urban issue, obscuring the visibility of its impacts in rural contexts, including the ways in which housing insecurity intersects with other health and structural inequities facing rural populations. Working to address this gap in the existing literature, this paper explores the experiences of housing insecurity in a rural context by reporting on an analysis of 210 in-depth interviews with 153 adults between the ages of 18-35, living in California's rural North State, a relatively overlooked far northern region of the state comprised of 12 north central and north eastern counties. Using in-depth qualitative interview data, we conducted an exploratory pattern-level analysis of participants' narratives structured by four dimensions of housing insecurity defined in the literature (housing affordability, housing stability, housing conditions, and neighborhood context). Drawing attention to the pervasiveness of rural housing insecurity within our sample, this analysis highlights the unique ways in which rurality creates distinct experiences not currently captured in the existing literature. Further research is needed across different types of rural communities to better understand the various ways that housing insecurity affects the everyday lives and health of rural residents. By grounding research within the experiences of rural residents, we are better able to respond to the crisis of rural housing insecurity and develop solutions that are tailored to rural residents' unique needs.

"I Can't Make Perfect Choices All the Time": Perspectives on Tobacco Harm Reduction Among Young Adults Who Identify as Sexual and Gender Minorities.

INTRODUCTION: Cigarette smoking is among the most harmful ways to consume nicotine and tends to be concentrated among socially marginalized groups of people, including sexual and gender minorities (SGM). Though some approaches to tobacco control in the United States are harm reduction strategies (eg, smoke-free environments), often abstinence is an explicitly stated goal and discussions of tobacco harm reduction (THR) are controversial, particularly for young people. Despite this controversy in the tobacco field, emerging research suggests that THR may be gaining momentum as a "community-led" rather than "public health-led" health practice. To date, little is known about how SGM young adults negotiate their use of tobacco products, particularly in terms of minimizing the harms associated with smoking. AIMS AND METHODS: We conducted 100 in-depth interviews with SGM young adults ages 18-25 years living in the San Francisco Bay Area, to better understand participant perceptions and everyday practices related to THR. RESULTS: A thematic analysis of interview narratives revealed the ways in which participants relied upon various THR strategies while balancing their well-being within the context of broader socio-structural harms. Participants' narratives also underscored beliefs about the importance of pragmatic, nonjudgmental, and person-centered approaches to preventing inequities in tobacco-related illnesses. CONCLUSIONS: Findings represent a significant departure from the mainstream discourse in the U. S. surrounding THR, by revealing how understanding the practice of THR among SGM young adults who use nicotine and tobacco can be instrumental in shaping approaches to tobacco control policy and prevention that may ultimately help to reduce inequities in tobacco-related illnesses. IMPLICATIONS: Findings from this study present the perspectives and practices of THR among sexual and gender minority young adults and emphasize the importance of integrating this approach in tobacco control to better achieve tobacco-related equity. Results can be used to better design tobacco prevention, treatment, and policy strategies that are compassionate and responsive to the needs of these important priority populations.

Incorporating Intersectionality as a Framework for Equity-Minded Tobacco Control Research: A Call for Collective Action Toward a Paradigm Shift.

INTRODUCTION: To eliminate tobacco-related disparities, tobacco control research would benefit from a paradigm shift. Intersectionality, a framework pioneered by Kimberlé Crenshaw in late 1980s, has the potential to improve our understanding of why and how certain social groups are disproportionately harmed by commercial tobacco use, and improve our ability to address persistent tobacco-related health disparities. AIMS AND METHODS: In this commentary, we outline the rationale and recommendations for incorporating intersectionality into equity-minded tobacco control research. These recommendations arose from intersectionality webinars organized by the Health Disparities (now Health Equity) Network of the Society for Research on Nicotine & Tobacco (SRNT) in 2019 and 2020. RESULTS: Specifically, we propose that eliminating tobacco-related disparities through intersectionality-informed research requires a multilevel, multipronged approach. We summarize priority actions for the tobacco control research field to achieve health equity through the intersectionality framework including acknowledging that structural factors, racism and power dynamics shape lived experiences, integrating critical theoretical frameworks and intersectionality scholarship into research questions, and embracing collaborative community-based approaches at every level of the research process. CONCLUSIONS: Through these actions, our field can take concrete steps to fundamentally improve our approach to conducting research to achieve health equity. IMPLICATIONS: Intersectionality is a valuable tool to align our field with our pursuit of health equity. The recommendations aim to improve methods of equity-focused tobacco control, prompt ongoing dialogue on the utility of this tool, and shift paradigms in how the research process is conducted at every level among stakeholders, including researchers, journal editors and reviewers, funders, practitioners, and policy makers.

Understanding the Impact of COVID-19 on Tobacco and Nicotine Use among Young Adults Identified as Sexual and Gender Minorities: A Mixed Methods Approach.

We investigated the perceived impact of COVID-19 on changes in tobacco and nicotine (NT) use among sexual and gender minority (SGM) young adults. We used a mixed methods approach that included closed- and open-ended survey questions and in-depth interviews. Participants were 53 SGM young adults in California who reported current or past cigarette smoking. Of study participants, 63% (n=33) reported any changes in their NT use, and of those, 60% reported initial increase of NT use. Content analysis of an open-ended survey question revealed three reported reasons for changes in NT use: (1) changes in routine activities (27%), (2) stress (46%), and (3) health (24%). Thematic analysis of qualitative interviews identified several related themes: (1) in discussions of increased NT use, stress and boredom/free time were important aspects of changes to daily routines, (2) fluctuations in NT use behaviors occurred over time, (3) reasons for NT changes were multiple and intertwined, and (4) NT use changes were shaped by experiences related to intersectional forms of structural and social stigmatization. Results reveal the dynamic and complex ways in which participants described their pandemic-related changes in NT use-nuance that is crucial for compassionate and participant-centered approaches to tobacco prevention and cessation.

Comparing conceptions of gender, sexuality and lesbian identity between baby boomers and millennials.

To answer this special issue provocation, Is Lesbian Identity Obsolete? we analyzed interviews with people who had identified at some point in their lives as lesbians, or as women/femmes who were attracted to women - some of them part of the Baby Boomer generation and some part of the Millennial generation. Participants from both generations rejected the gender binary. Nevertheless, we found a shift away from understanding gender as an oppressive category to an understanding of gender as a proliferating identity in which one may play with gender in an intentional and creative manner. It appears that participants across generations articulated their sexual identities strategically to express not only a sexual orientation but more importantly political and community alliances. For Baby Boomer lesbians, lesbian identity connoted an alliance with feminism, and for Millennials their sexual identity indicated a political alliance with queer and trans* movements. In order to sustain solidarity between lesbians of different generations, we suggest that narratives about gender should include both intrinsic and extrinsic components. We further suggest that the political project of ending the oppression of all lesbians/women who love women is fraught, but essential in a world that hates women.

Pathways of Nicotine Product Use: A Qualitative Study of Youth and Young Adults in California.

INTRODUCTION: Existing research on youth's adoption of alternative nicotine delivery systems (ANDS) has focused on identifying pathways of nicotine product use, specifically examining whether vaping encourages progression to smoking. Few studies have considered other pathways of initiation. Qualitative studies suggest that meanings of vaping vary significantly, suggestive of the need for a more nuanced understanding of the role of vaping for youth with different pathways into vaping and smoking. METHODS: We conducted in-depth qualitative interviews with 49 Californian youth between 15 and 25 years old who reported ever vaping nicotine to gain a deeper understanding of their initiation pathways of vaping and smoking, paying special attention to youth's experiences and reasons for ANDS initiation and use. Categorizing participants into initiation pathways by self-reported use and age of initiation of ANDS and cigarettes, we then compared the meaning and role of vaping across three distinct pathways of use: (1) smoking to vaping, (2) vaping to smoking, and (3) vaping only. RESULTS: The most common pathway reported was smoking to vaping (74%), eight participants began vaping before smoking, and five participants reported only vaping but never smoking. Analysis of participants' narratives emphasized that youth in our study, regardless of initiation pathway, were generally aware of the health consequences of smoking and negotiated their use of nicotine products considering relative risks. CONCLUSION: Findings from this study suggest that ANDS serve as a transitional tool for youth who are keenly aware of the health consequences of smoking, thus challenging conventional discourses about ANDS as a threat to youth's health. IMPLICATIONS: This qualitative study queries concerns about the potential of alternative nicotine delivery systems (ANDS) to serve as a gateway into cigarette smoking for youth and young adults. Findings suggest that most of the youth participants discussed and considered relative risks in their pathways of initiation, highlighting the need to acknowledge harm reduction in constructing public health messaging and policies for smoking cessation.

Trans adolescents' perceptions and experiences of their parents' supportive and rejecting behaviors.

Transgender (trans) adolescents consistently report higher rates of adverse mental health outcomes compared to their cisgender peers. Parental support is a recognized adolescent protective factor; however, little is known about the specific parental behaviors that trans adolescents perceive as most or least supportive. To address this gap, we analyzed data from qualitative interviews conducted with an ethnically diverse, urban-based sample of trans adolescents (N = 24; 16-20 years old) to describe (a) the spectrum of specific parental behaviors across 3 categories-rejecting, supportive, and mixed (i.e., simultaneous supportive and rejecting behaviors)-and (b) the perceived psychosocial consequences across these 3 categories of parental behaviors. Qualitative data were gathered through lifeline interviews (i.e., visual representations from birth to present) and photo elicitation (i.e., photographs representing parental support and/or rejection). Supportive behaviors included instances where parents made independent efforts to learn about trans issues or help their child obtain gender-affirming health care. Rejecting behaviors included instances when parents refused to use their child's name or pronouns or failed to show empathy when their child struggled with gender-identity-related challenges. Mixed behaviors included examples when parents expressed support of their child's gender identity, but not of their sexual orientation (or vice versa). Overall, participants reported that rejecting and mixed parental behaviors contributed to a range of psychosocial problems (e.g., depression and suicidal ideation), while supportive behaviors increased positive wellbeing. These findings expand upon descriptions of parental support and rejection within the trans adolescent literature and can help practitioners target specific behaviors for interventions. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

The Role of Multiple Social Identities in Discrimination and Perceived Smoking-Related Stigma among Sexual and Gender Minority Current or Former Smokers.

AIMS: We investigated how intersections of being a racial minority (i.e. being African American) and economically-disadvantaged (i.e. housing insecurity) may influence experiences with discrimination and perceptions of smoking-related stigma among sexual and gender minority (SGM) current and former smokers. Methods: Survey data were collected from 227 SGM current and former smokers in California (19-65 years old), oversampling African American participants. Participants reported their race, ethnicity, past month housing insecurity, number of lifetime experiences with SGM discrimination, and perceptions of smoking-related stigma. FINDINGS: Using univariate General Linear Models and controlling for age, ethnicity, and SGM visibility, we found a significant interaction between being African American and facing housing insecurity on experiences with SGM discrimination [F(1,220)=7.21, p=0.01], perceived smoker stigma [F(1,220)=5.48, p=0.02], perceived differential treatment due to smoking [F(1,220)=10.03, p=0.00], and social withdrawal from non-smokers [F(1,220)=6.18, p=0.01]. These interactions suggest that economically-disadvantaged African American SGM current or former smokers experience increased levels of discrimination and perceive more smoking-related stigma compared to other SGM current and former smokers. Conclusions: Results suggest that people's multiple identities intersect to intensify oppression and inequities for some people and raise questions about the unintended consequences of stigmatizing smokers for reducing smoking among SGM adults.

The "here and now" of youth: the meanings of smoking for sexual and gender minority youth.

BACKGROUND: The mainstream tobacco field in the USA tends to situate youth as passive, particularly in terms of their susceptibility to industry manipulation and peer pressure. However, failing to acknowledge youths' agency overlooks important meanings youth ascribe to their tobacco use and how those meanings are shaped by the circumstances and structures of their everyday lives. METHODS: This article is based on analysis of 58 in-depth qualitative interviews conducted with sexual and gender minority youth living in the San Francisco Bay area in California. Topics covered in interviews focused on meanings of tobacco in the lives of youth. Interviews lasted approximately 2.5 h and were transcribed verbatim and linked with ATLAS.ti, a qualitative data analysis software. Following qualitative coding, narrative segments were sorted into piles of similarity identified according to principles of pattern-level analysis to interpret to what extent meanings of smoking for young people may operate as forms of resistance, survival, and defense. RESULTS: Analysis of our participants' narratives highlights how smoking is connected to what Bucholtz calls the "'here-and-now' of young people's experience, the social and cultural practices through which they shape their worlds" as active agents (Bucholtz, Annu Rev Anthropol31:525-52, 2003.). Specifically, narratives illustrate how smoking signifies "control" in a multitude of ways, including taking control over an oppressor, controlling the effects of exposure to traumatic or day-to-day stress, and exerting control over the physical body in terms of protecting oneself from violence or defending one's mental health. CONCLUSIONS: These findings call into question the universal appropriateness of foundational elements that underlie tobacco control and prevention efforts directed at youth in the USA, specifically the focus on abstinence and future orientation. Implications of these findings for research, prevention, and policy are discussed, emphasizing the risk of furthering health inequities should we fail to acknowledge the "here and now" of youth.

Conceptualizing ethnicity in alcohol and drug research: Epidemiology meets social theory.

Since the 1990s, social scientists have rejected notions of ethnicity as something static and discrete, instead highlighting the context-dependent and fluid nature of multiple identities. In spite of these developments, researchers within the substance use fields continue to assess ethnic group categories in ways that suggest little critical reflection in terms of the validity of the measurements themselves, nor the social, bureaucratic, and political decisions shaping standard measures of ethnicity. This paper highlights these considerations, while also acknowledging the role of socially-delineated ethnic categorizations in documenting health inequities and social injustices. We call on researchers in alcohol and drugs research to critically appraise their use of ethnic categorizations, querying how to best measure ethnicity within their own studies in ways that are justified beyond simplified explanations of social convention and that "do no harm" in terms of perpetuating racism and obscuring the roots causes of social and health problems related to alcohol and drugs.

Tobacco Denormalization as a Public Health Strategy: Implications for Sexual and Gender Minorities.

Although the population-level success of tobacco denormalization is widely accepted, it remains unclear whether these strategies alleviate health inequities for sexual and gender minorities. The high risk of smoking among sexual and gender minorities together with research that documents a relationship between stigma-related processes and smoking prevalence for these groups raises questions about whether tobacco-related stigma intensifies the disadvantages associated with the stigmas of other social identities. We have not adequately considered how tobacco-related stigma overlaps with other social identity stigmas. Given concerns about the intensification of inequality, this type of inquiry has important implications for understanding both the effectiveness and limitations of tobacco denormalization strategies for sexual and gender minorities and identifying those tobacco prevention, treatment, and public health policies that work to ameliorate health inequities.

The Role of Drinking Beliefs to Explain Ethnic Variation in Drinking Practices Among U.S. College Students.

This study, funded by the National Institute on Alcohol Abuse and Alcoholism, examines psychosocial mediators to explain discrepancies in past-30-day drinking between African American and White college student drinkers in the United States. Between 2008 and 2010, 5,845 college drinkers completed an online survey about their alcohol use. Using latent variable structural equations modeling, we investigated the relationships between ethnicity, drinking beliefs, and students' past 30-day alcohol use. Drinking beliefs-i.e., positive expectancies, perceived norms, and disapproval of alcohol use-fully mediated the relationship between ethnicity and drinking behaviors. Study limitations and directions for future research are discussed.

Harm perceptions of vaping nicotine relative to cigarette smoking among sexual and gender minority young adults.

INTRODUCTION: To address gaps in existing research, the current study used a mixed-methods approach to describe, contextualise and understand harm perceptions of vaping nicotine relative to cigarette smoking and associations with nicotine and tobacco (NT) use among young adults who identify their genders and sexualities in ways that classify them as sexual and gender minorities (SGM). METHODS: Results are based on cross-sectional surveys and online qualitative interviews with 98 SGM young adults (18-25 years old) in California's San Francisco Bay Area who currently or formerly used combustible tobacco. We generated a measure assessing participants' relative harm perceptions of e-cigarette use versus cigarette smoking and identified those who perceived cigarette smoking as more harmful than e-cigarette use compared to those who perceived it to be equally or less harmful. RESULTS: We found that relative harm perceptions of cigarette smoking versus e-cigarette use are likely related to much uncertainty and confusion about the harms of e-cigarette use. Moreover, findings illustrate that public health messages regarding the risks of e-cigarette use may have unintended consequences of increasing cigarette use to replace e-cigarette use for some SGM young adults, a practice that is incongruent with scientific evidence demonstrating that cigarettes and other combustible tobacco products are riskier than e-cigarettes and other forms of NT use. DISCUSSION AND CONCLUSIONS: Results suggest the need for evidence-based, clear, and direct messaging about the relative harms of cigarettes versus e-cigarettes to reduce NT-related inequities in SGM populations.

Food choice as a multidimensional experience. A qualitative study with young African American women.

As obesity persists in the United States, many public health interventions have been conceived to encourage people to change their diets. These interventions are based on encouraging people to prioritize healthier alternatives in food choice. However a consideration of the existing but limited literature on food choice for diverse populations renders such an assumption problematic. This qualitative study examined the food choices of a population most at risk for obesity - low-income African American women - by considering psychological factors, social and cultural meanings of foods, and structural conditions that shape how women decide what to eat. Interviews revealed the complexity of their food choices, illustrating the extent to which multiple influences operate simultaneously on food choice decisions. Implications for obesity prevention are discussed, in particular highlighting the problem that some types of public health interventions do not correspond to the lived experiences of the populations they intend to target.

Tobacco Harm Reduction as a Path to Restore Trust in Tobacco Control.

The controversy of tobacco harm reduction in the United States persists despite evidence that an important audience of tobacco prevention and control, i.e., the people who use or are likely to use nicotine and tobacco products, are engaging in practices that may be considered harm reduction. Despite this, a significant proportion of the US tobacco control and prevention field continues to be guided by a precept that there is "no safe tobacco," therefore failing to acknowledge practices that may be used to reduce the harms associated with consuming combustible forms of nicotine and tobacco. In this commentary, we argue that ignoring the potential benefits of harm reduction strategies may unintentionally lead to an erosion of trust in tobacco control among some members of the public. Trust in tobacco control as an institution is crucial for the success of tobacco control efforts. To ensure trust, we must return to our basic principles of doing no harm, developing programs that are responsive to people's experiences, and providing resources in assisting people to reduce the harms that may be associated with practices, such as smoking, which adversely affect health. Only by respecting an individual's priorities can we cultivate trust and develop tobacco prevention efforts that are grounded in the realities of people's lives and responsive to their needs.

Is Smoking Queer? Implications of California Tobacco Denormalization Strategies for Queer Current and Former Smokers.

This article is concerned with normative conceptions of health structuring tobacco control strategies designed to "denormalize" tobacco use. Analysis of 201 interviews with non-heterosexual and/or non-cisgender adults in California revealed that participants implicated tobacco use in exacerbating health inequities and perpetuating harmful narratives of queer suffering, but also regarded smoking as a critical tool for self-care and symbol of resistance. Participant narratives suggest that using stigma in health promotion efforts which reinforce normative conceptions of health may be harmful to queer people whose social identities exist within ongoing legacies of pathology, health stigma, and deviance from hegemonic structural norms.

Intersecting Sexual Identities, Oppressions, and Social Justice Work: Comparing LGBTQ Baby Boomers to Millennials Who Came of Age After the 1980s AIDS Epidemic.

In this study we analyze 50 interviews with racially diverse, predominantly low-income, LGBTQ participants living in the San Francisco Bay Area. Rooted in intersectional theory that conceptualizes identities as shaped by interlocking forms of oppression and privilege, we compared interviews with "Baby Boomers" to those with "Millennial" participants, who came into adulthood in a time of greater legal and social inclusion for LGBTQ people. Our analysis focused on three questions: How do participants understand their sexual identities? How are the identities of sexual minority participants co-constructed with intersecting forms of oppression? What motivates LGBTQ people in our sample to engage in social justice work? We found that white LGBTQ people tended to see their sexualities as primary to their identity, compared to LGBTQ Black and/or Indigenous People of Color (BIPOC) who tended to see their identities in intersectional terms. Younger LGBTQ people were more likely to delink sex and gender identity; consequently, they were more likely to frame their sexual identities with terms not rooted in a gender binary (e.g., pansexual or queer). Experiences with homophobia were prevalent across generations, and intersected with racism and economic oppressions, but younger people more often described support from institutional agents. Participants' sense of community and commitment to giving back after experiences of trauma motivated them to engage in social justice work. Our findings highlight the intersectional nature of oppressions faced by LGBTQ people and the need for organizations to move away from focusing exclusively on homophobic oppression as a monolith.

SUBSTANCE USE AMONG SEXUAL AND GENDER MINORITIES: ASSOCIATION WITH POLICE DISCRIMINATION AND POLICE MISTRUST.

We investigated associations between experiences with police discrimination, police mistrust, and substance use in a convenience sample of 237 sexual and gender minority (SGM) adults in California. In a cross-sectional survey, collected between January 2016 and July 2017, participants reported substance use, lifetime experiences with SGM-related police discrimination, police mistrust, demographics and SGM visibility. In adjusted logistic regression models, we found a positive association between lifetime police discrimination and past-two-week heavy episodic drinking. Police mistrust also was positively associated with past-month marijuana use. Several significant interactions between lifetime police discrimination or police mistrust with other socially stigmatized identities including being African American, insecure housing, and being a gender minority on a few substance use outcomes suggest that effects of police discrimination and mistrust on substance use are stronger among participants with multiple stigmatized identities. Results suggest the importance of policies and interventions that focus on eliminating police discrimination and increasing police legitimacy to reduce risk of substance use among SGM individuals.