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

Abstract

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.

This commentary outlines a rationale for incorporating intersectionality into equity-minded tobacco control research. Our intention is to provoke robust discussion among tobacco control stakeholders including researchers, journal editors and reviewers, policy makers, funders, and practitioners to encourage the formal integration of intersectionality in all equity-minded tobacco control research. Of note, this commentary focuses on commercial tobacco (i.e., mass-produced and mass-marketed products) rather than sacred ceremonial tobacco.¹

The current challenges in commercial tobacco control would benefit from an innovative paradigm shift. Intersectionality, a framework pioneered by Kimberlé Crenshaw in late 1980s,² has great potential to improve our understanding of why and how certain social groups are disproportionately harmed by commercial tobacco use.³ Intersectionality-informed approaches to tobacco control research will generate important insights to accelerate the progress of eliminating tobacco-related disparities. Recognizing contextual differences in the operationalization of social identity, privilege and disadvantage, governance, tobacco control policies, and societal/cultural norms across global geographic regions, this commentary highlights the application of intersectional approaches in the United States and acknowledges that an intersectional approach is likely to vary depending on context.

Rationale for a paradigm shift to incorporate intersectionality into equity-minded tobacco control research. Intersectionality identifies, uncovers, and seeks to understand the complex interdependent systems of oppression and disadvantage linked with social identities. Race, ethnicity,⁴ socioeconomic position, religion, indigeneity,⁵ sex, sexuality, and gender identity⁶ are each embedded in societal structures associated with access to power. These social identities create unique, complex lived experiences that cannot be fully understood by focusing on individual identities in isolation.^2,7 Multiple social identities have unique, interactive, and co-constitutive effects on lived experiences,^8,9 which are essential to understanding the development and maintenance of tobacco-related health disparities.

A paradigm shift to deliberately incorporate these ideas in tobacco control research requires a critical mass of equity-minded researchers embracing an intersectional approach. The critical mass of multiple stakeholders spanning basic science, clinical, epidemiological, social and behavioral, and policy research is required. The proposed shift also requires a radical re-evaluation of how knowledge and knowledge-generation are valued. For instance, deliberate incorporation of intersectionality into the research process will require a re-evaluation of established standards that position conventional “experts” as gatekeepers of knowledge, a revision of the types of research questions asked, a re-assessment of the relative value of different research methods, and a re-appraisal of how researchers are evaluated and recognized for their work. An active awareness of power structures in our research institutions and how these shape our research and translational approaches and impact communities who are exploited by commercial tobacco is required. A critical examination of the power structures and dynamics in the research enterprise and how these factors contribute to our failure to reduce harms of commercial tobacco in many communities is necessary for meaningful change.

Intersectionality challenges conventional Euro-western academic notions of objectivity in research, requiring researchers to question and declare relevant social identities and experiences. Conventional Euro-western quantitative approaches, developed by members of privileged social groups, assume certain norms and perspectives without questioning objectivity. Quantitative methodologies have thus come to dominate research framework in the social and biological sciences, which has had a significant impact on promoting privileged social perspective and determining the values and priorities of research questions, variables of interest, analytical approaches, and interpretations of findings. This limited perspective has contributed to inequities in evidence-based approaches to tobacco control and the undervaluation of research and research questions that would benefit marginalized groups.

Key tenets of intersectionality include social inequality, power, relationality, social context, complexity, and social justice.¹⁰ Embedded within a constructivist worldview, several theoretical perspectives contain one or more key tenets of intersectionality, including feminist theory,¹¹ political economic theory,¹² critical race theory,^13,14 critical Indigenous theory,^15,16 and queer theory.¹⁷ A significant epistemological re-orientation of tobacco control research to integrate these theoretical perspectives will enable a framing of tobacco-related disparities as manifestations of historical, structural, and societal forces. For example, critical race theory (CRT) examines how racism has been created and maintained by core social organizational structures, for example, laws and law enforcement.¹⁴ CRT-oriented tobacco research might interpret smoking among individuals of African descent in the context of segregated education, housing, and employment.⁴ Such perspectives relocate the locus of responsibility for change from pathologized individual members of marginalized communities to broader social systems. These social systems lead to disproportionately higher access to and dependence on commercial tobacco products, lucrative targeting by the tobacco industry, a lack of access to tobacco treatment and prevention services, and unequal protections from tobacco control. Moreover, an intersectional approach integrates multiple perspectives and contexts, so that the smoking behaviors of queer Black women, for example, are understood to result from a multiplicity of social oppressions distinctly different from those experienced by queer White women, straight Black women, queer Black men, and the intersection of other racialized-gender-sex identity groups.

Actions the tobacco control research field can take to embrace intersectionality. Eliminating tobacco-related disparities through intersectionality-informed research requires a multilevel, multipronged approach. Table 1 summarizes our proposed list of priority actions and associated stakeholders. First, we must identify the pervasive and powerful structural factors that shape the lived experiences of individuals and communities affected by oppression. We must then begin to understand how these factors result in individual, societal, and intergenerational harms from commercial tobacco use. We must recognize that enacting policy and other social structural interventions are our most potent tools to influence lasting change in marginalized populations instead of placing the entire burden of change on marginalized groups. For instance, beyond direct tobacco control efforts (e.g., restricting marketing and sales of flavored tobacco, increasing tobacco taxation), we must implement policy changes such as increasing access to mental health care, affordable housing, and passing and enforcing antidiscrimination laws to address what many communities identify as the root causes of tobacco use among lower income groups, Indigenous people, Black, other racialized groups, rural populations, and sexual and gender minority individuals.

Table 1.

Selected Priority Actions for Achieving Health Equity Through the Intersectionality Framework

	Researchers	Institutions	Journals	Funders	Practitioners	Policy makers
• Acknowledge that structural factors, racism and power dynamics shape lived experiences; shift focus to address both individual-level behavior change and dismantle structural and racial inequities that impede individual behavior change.	✓	✓	✓	✓	✓	✓
• Integrate critical theoretical frameworks (feminist theory, political economic theory, critical race theory, critical Indigenous theory, and queer theory, among others) and foundational intersectionality scholarship into original research questions	✓	✓	✓
• Embrace collaborative, community-based approaches at every level of the research process (including leadership, data collection, interpretation, and dissemination of findings)	✓	✓	✓	✓	✓	✓
• Promote cultural and linguistic competence	✓	✓	✓	✓	✓	✓
• Consider collaborations with qualitative/mixed-methods researchers knowledgeable of critical theories and frameworks that shift focus from a positivist/post-positivist to constructivist lens	✓	✓	✓	✓
• Incentivize researchers to actively pursue an intersectional framework/paradigm	✓	✓	✓	✓
• Increase funding for diverse and emerging scholars, community-based participatory research, and mixed-methods studies	✓	✓		✓
• Modify journal review guidelines to emphasize the necessity of intersectional considerations at every stage of research	✓		✓
• Use person-first language and avoid overly simplistic descriptions of personhood and groups	✓	✓	✓		✓	✓
•Acknowledge and specify differences between commercial and traditional tobacco use	✓	✓	✓	✓	✓	✓

Second, we need to require the integration of intersectionality teaching and scholarship across various research disciplines spanning basic science, clinical, epidemiological, social and behavioral, and policy research. This will help ensure that intersectionality-grounded research questions are asked and answered. For instance, a recently developed web-based training on treatment of tobacco use among groups that experience tobacco-related disparities includes a module grounded on intersectional scholarship.¹⁸ Similar trainings could be developed for researchers and practitioners across our field.

Third, we must embrace collaborative, power-sharing, community-based approaches at every step of the research continuum, including establishing leadership, data collection, and interpretation and dissemination of findings. By engaging with community members as equal colleagues throughout the research process, and by valuing and advancing community-based standards of evidence equitably, the gatekeeping inherent in conventional academic channels may give way to collaborative, accountable actions more aligned with social justice. Moreover, community-engaged approaches can promote cultural and linguistic competence in our research design, approaches, and interventions. This shift will help to upend power imbalances in our knowledge creation process. For example, the SRNT Health Equity Network sponsored a symposium at the 2021 Annual SRNT Conference focused on community-engaged research approaches and included community organization leaders as presenters.¹⁹ In addition, California’s Tobacco-Related Disease Research Program offers funding opportunities to promote community-based participatory research, where academic researchers and community members are co-equal partners.

Fourth, we need to reform incentive structures to encourage the pursuit of intersectionality-informed research. Sustained and substantial funding to support diverse and emerging scholars, community-based participatory research, case studies and mixed-methods studies are essential to maintain long-lasting improvements in tobacco-related health equity. Funding opportunities can promote intersectional approaches, and peer-review panels with the appropriate expertise can be instructed to value applications accordingly. Journal editors and reviewers need to emphasize the necessity of incorporating intersectional considerations in manuscripts.

Fifth, we need to replace identify-first language that labels individuals by behavior, disorder, or social category ahead of personhood (e.g., smokers, Blacks) with person-first language (e.g., individuals who smoke, Black individuals or people).²⁰ Overly simplistic descriptions of personhood and social groups is dehumanizing and contributes to stigma, discrimination, and marginalization. Person-first language encourages empathy and supports a deeper appreciation of multiple dimensions of the personhood of individuals. Language norms established by dominant groups (e.g., tobacco industry use of the term “smoker”) are important structural barriers to addressing tobacco-related health disparities.

We believe we provide a compelling rationale for incorporating intersectionality into equity-minded tobacco control research. We believe that the actions delineated above will fundamentally improve tobacco research and generate robust discussion among tobacco control stakeholders. We look forward to continuing this conversation as we come together to address tobacco-related inequities.

Supplementary Material

A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr.

Funding

JTH is supported by grant number T32HL140290 from the National Heart, Lung, and Blood Institute at the Steve Hicks School of Social Work at the University of Texas at Austin, as well as support from grant P2CHD042849, Population Research Center, The University of Texas at Austin by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. CES’s work was supported by grant number R25CA233416 from the National Cancer Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. JPL’s work was supported by grant number T29IP0508HC from the University of California Office of the President’s Tobacco-Related Disease Research Program. ASLT’s work was supported by grant number R01CA237670 from the National Cancer Institute and grant numbers R21DA052421 and R01DA054236 from the National Institute on Drug Abuse.

Declaration of Interests

The authors have no financial or conflicts of interests to declare.