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'Risking enchantment': how are we to view the smoking person?
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PMID:  23060687     Owner:  NLM     Status:  Publisher    
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The idea of the smoking person portrayed in public health has been criticised as being based on too narrow a view of human nature. This article discusses that view: that of a person with a stable core and epiphenomenal 'behaviours' that can be removed by rational persuasion or Pavlovian manipulation, and examines social scientific critiques of it. The social sciences explore the meanings smoking has for individuals and portray human identity as malleable, the result of ongoing interactions with human and non-human others. Aspects of smokers' experience revealed in qualitative research - descriptions of cigarettes as 'companions' or 'friends', deep reliance, sensual pleasure - are sometimes difficult to articulate but can be given full voice in the context of the literary arts. We explore some examples of these sources and argue that a complete picture of smoking meanings is impossible without reference to them. We take a pragmatic approach, following the philosopher William James, who argued that emotional and spiritual experiences contribute to the truth of human existence as much as material explanations, to suggest that this understanding should be part of a critical but supportive engagement with public health research in order to develop more nuanced and humane approaches to smoking cessation.
Authors:
Jane Macnaughton; Susana Carro-Ripalda; Andrew Russell
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Publication Detail:
Type:  JOURNAL ARTICLE     Date:  2012-7-24
Journal Detail:
Title:  Critical public health     Volume:  22     ISSN:  0958-1596     ISO Abbreviation:  Crit Public Health     Publication Date:  2012 Dec 
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Created Date:  2012-10-12     Completed Date:  -     Revised Date:  -    
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Nlm Unique ID:  9810774     Medline TA:  Crit Public Health     Country:  -    
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Languages:  ENG     Pagination:  455-469     Citation Subset:  -    
Affiliation:
Centre for Medical Humanities, School of Medicine and Health, Durham University, Durham, UK.
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Journal ID (nlm-ta): Crit Public Health
Journal ID (iso-abbrev): Crit Public Health
Journal ID (publisher-id): ccph
ISSN: 0958-1596
ISSN: 1469-3682
Publisher: Taylor & Francis
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Received Day: 7 Month: 12 Year: 2011
Revision Received Day: 1 Month: 6 Year: 2012
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Print publication date: Month: 12 Year: 2012
Volume: 22 Issue: 4
First Page: 455 Last Page: 469
ID: 3464452
PubMed Id: 23060687
DOI: 10.1080/09581596.2012.706260

‘Risking enchantment’: how are we to view the smoking person?
Jane Macnaughtona*
Susana Carro-Ripaldab
Andrew Russellb
aCentre for Medical Humanities, School of Medicine and Health, Durham University, Durham, UK
bDepartment of Anthropology, Durham University, Durham, UK
*Corresponding author. Email: jane.macnaughton@durham.ac.uk

From East Coker, by T. S. Eliot

There is, it seems to us,

At best, only a limited value

In the knowledge derived from experience.

The knowledge imposes a pattern, and falsifies,

For the pattern is new in every moment

And every moment is a new and shocking

Valuation of all we have been.

(Eliot 1974)


Introduction

A recent thematic issue of this journal offers a critique of public health policy in relation to drinking, smoking and obesity (Bell et al. 2011), discussing the ways in which current biomedical culture characterises the body as the passive victim of these ‘epidemics’ and ‘addictions’. Other articles raise awareness of the extent to which medical culture dominates public health discourse in relation to smoking. Such approaches lead us outside the narrow context of health concerns into an analysis of why it is that tobacco smoking remains such a pervasive habit despite the many health problems it has been proved to cause. Dennis (2011) uses ideas from Merleau-Ponty to draw attention to the embodied experience of smoking. She explores the idea of an unbounded human body extending into the space which surrounds it, affecting and being affected by that space in a way that the bounded, compartmentalised, biomedical body is not. Bunton and Coveney (2011) remind us that human beings are motivated by pleasure and categorise some of the ways in which the pleasure principle might apply in respect of ‘drugs’ like tobacco. Mair's (2011) focus is on the ‘behavioural turn’ in public health, noting that this approach separates the person from the behaviour, leading to a potentially distorting tendency to study, count and treat instances of the behaviour rather than the person who smokes.

What unites these approaches is an attempt to broaden how public health understands the human subject. Images and understandings of human beings in public health are not casual or inert. First of all, they have specific, intentional, directional histories, or ‘archaeologies’ and ‘genealogies’ in Foucauldian terms. Thus, present ideas about persons in public health could be traced to the emergence of biopower in the nineteenth century (Foucault 1978); that is, to a momentous concentration of technologies of power around life (Rabinow and Rose 2006) and its ‘management’. Second, public health's images and ideas of the person have effects. On the one hand, classifications can affect the very people they classify (Hacking 2004), and can serve to reify negative moral judgements towards them (Mair 2011). On the other hand, understanding human beings in certain ways for the purpose of research or intervention can serve to reify hegemonic or authoritative discourses and thus legitimate those very understandings of people and their loci as objects for further research and intervention (Eakin et al. 1996, Mair and Kierans 2007).

Although ideas and concepts of the person in public health can thus be considered not entirely innocent, they are nevertheless well meant. Public health, as other health agencies and institutions, has ‘life, not death, as their telos’ (Rabinow and Rose 2006, p. 203). Yet public health is embedded within the main mechanisms of biopower: a tendency to create and consolidate truth discourses and their authoritative figures; a commitment to intervention; the use of technologies for attaining specific forms of subjectification (Rabinow and Rose 2006). This embeddedness makes it almost impossible for the discipline to escape its own particular gaze and modes of knowledge, and thus its own constituted ideas of what persons are, how they operate and how they can be ‘changed’. If we accept in ethical terms public health's right to intervene in people's lives with the object of enhancing health or extending life, we might nevertheless object that these interventions are based on an ill-informed — or at least partially informed — set of ideas about the human being.

Focussing on research and interventions in the field of tobacco control, the aim of this article is to outline what views of the ‘smoking person’ are assumed by these activities, and to argue for an expanded perspective that draws upon a wider range of sources through which to understand the experience of smoking. We argue that other fields of knowledge, both in the social sciences and the humanities, provide alternative and critical views which could help public health move towards a more humanistic, nuanced view of the person. In particular, we propose that what may be missing in public health's conceptualisations of people is the ‘existential’ evidence provided by the literary and creative arts. We suggest that an acceptance on the part of tobacco control researchers and practitioners of what might be regarded as ‘soft-touch’ forms of knowledge (as in ethnographic, phenomenological or narrative approaches) could result in a more empathetic and compassionate understanding of persons in all their fluidity, contradiction and humanity. An incursion into hitherto unexplored theoretical and pragmatic fields in the social sciences and humanities could lead to entirely different understandings of what is to be human, and the position of this entity within a web of social, political and economic complexity that demands a critical reassessment of the foci of research and intervention efforts (Kohrman and Benson 2011, Mair 2011).


Views of the human in smoking-related research and practice

There are many reasons why smoking still has a prevalence of around 21% in both the UK and the USA (CDC 2010, ONS 2011). Some are intimately tied up with the fact that humans are complex beings whose ideas about what makes them who they are and able to live well may not necessarily be related to what makes their bodies healthy. This complexity is not, however, reflected in the ways that public health researchers investigate smoking.

Much smoking research has been carried out in the context of clinical medicine or public health and is preoccupied with getting people to stop. In an article published in this journal in 2007, Mair and Kierans argue that the concatenation of much tobacco research with tobacco control is problematic. These authors point out that in a context in which tobacco research is goal-oriented and directed at cessation, and where tobacco is seen as an ‘epidemiologiocal phenomenon’ (Mair and Kierans 2007, p. 106), smoking tends to be defined as a ‘disease’, ‘disorder’ or ‘deficits in the individual or among groups of individuals’ (p. 107). This epidemiological interpretation of smoking turns the epidemic into the agent, and the people who smoke into mere vessels for its expression.

Even when tobacco control scholars or practitioners try to expand the scope of their investigations to include contextual information, they can fall into epistemological and methodological traps. Research in clinical practice settings can be particularly revealing in this regard. Copeland (2003) explored smoking among disadvantaged women aiming to ‘identify what role smoking has in the lives of the study group’. The methods, however, consisted of getting women to fill in the Hospital Anxiety and Depression Scale, a knowledge of health risks measure, a measure of opinions on the effectiveness of smoking cessation practices and an open-ended questionnaire on smoking. It would be difficult, given the anti-smoking steer from the chosen methods, to elicit responses other than ‘guilt’ about not giving up smoking. There was also little scope to explore what it might be about smoking that is identity-making, relational, contextual or even positive or enjoyable.

The principles that guide this type of research, as well as the epistemological assumptions and the choice of methods, determine the particular visions of smoking individuals which result from such studies. On the other hand, and in a circular fashion, pre-existing and reified ideas about the smoking person continue to inform the specific epistemological and methodological choices in subsequent tobacco research, thus legitimising both object and forms of investigation. This vicious circle not only limits public health and tobacco control's potential for conducting effective anti-tobacco work, rooted in a real understanding of the wider realities, but also has the capacity to stigmatise and marginalise specific classes of persons or sub-groups by attributing certain ‘smoking’ characteristics to them and by repeatedly picking them as targets for anti-smoking interventions (Mair 2011). As Hacking (2004) notes, classifications affect people, not so much because of people's knowledge of such categorisations, but because of the way in which classifications guide the purpose and actions of relevant institutions.

But what are those classifications, those ideas and concepts that both inform and result from tobacco control research and practice? We will briefly present some of the general visions of the smoker which can be found in public health and clinical contexts, although we will not develop their origins or the exact consequences of their application, which fall outside the scope of this article.

The smoker as agent

Pilnick and Coleman (2003) provide rich evidence of GPs’ desperate attempts to engage reluctant quitters in conversation about their smoking. The frustration generated when contradictory worldviews collide is plain to see in their accounts. For the patient, smoking is so significant, so much a part of their being, that addressing the addiction or the health consequences alone is not enough to help them stop. For the doctor, this is inexplicable: if smoking is ruining their health, why do they persist in their habit? Why do they not make a rational, informed decision to quit?

What this example from a clinical context offers is a widespread medical and public health view of smokers as rational agents who need only to be presented with the facts to respond appropriately. This approach to smoking in public health has a history dating back to the UK Royal College of Physicians’ 1962 report on smoking.1 It is clearly in evidence in a short populist book by the architect of that report, Charles Fletcher, which was intended to give clear information to the public about the dangers of smoking (Fletcher et al. 1963). Similar assumptions about public rationality underpin a campaign in New Zealand encouraging health professionals to ‘Ask About the Elephant’ — the elephant in the room being the ignored or unaddressed problem of smoking (New Zealand Government Midcentral District Health Board 2011). More visceral emotions are invoked by an Australian anti-smoking campaign with its graphic pictorial health warnings and television adverts featuring blackened lungs on mortuary slabs, failing hearts and patients with horrific mouth cancer (Brennan et al. 2011). A similar approach has been taken by TV adverts in the UK showing the slow deterioration of a woman with chronic obstructive pulmonary disease through the eyes of her son (Fresh Smoke Free North East 2011). Yet tobacco control studies reveal that shocking, fear-inducing campaigns designed to ‘scare people straight’ (Thompson et al. 2009a) do not necessarily have the desired effect (Cook and Bellis 2001, Gilbert 2005, Davis et al. 2007, Heikkinen et al. 2010). Thompson et al. (2009a) suggest that for people with low levels of ‘efficacy’, such campaigns may generate defensiveness, avoidance or active opposition.

Dennis (2011) explores smokers’ creative resistance to a undirectional future in which their blackened lungs end up on a mortuary table, as portrayed in an antismoking advertisement. Such resistance may be to the closing down of potentiality in the future body that such advertisements connote, or to the rupture with their embodied self and habited past that abandoning smoking will require. For other smokers, resistance may signify contrariness or rebelliousness: an intention to court risk and cause damage to themselves and others, possibly even rejoicing in the failure of public health and tobacco control programmes to bring them into the fold and rescue them from their own potentially fatal behaviour. We glimpse this characterisation in Dennis’ interviews with smokers on their response to anti-smoking advertising (Dennis 2006): ‘The ads have the reverse effect on me; it reminds me that it's probably time for one’. Thompson et al. (2009b) also identify this response in their quote from a lapsed ex-smoker having a sly smoke on a night out: ‘There must be an element of wanting to belong to that crowd … those health-conscious nut cases are behind me … It's like regaining youth and Bourbon drinking’.

Public health's and tobacco control's vision of the smoker as an agent — either rational or perverse — does not necessarily yield positive results in interventions, and fails to address what motivates people to start and continue smoking in the face of so much anti-tobacco information. Nor do smokers and smoking exist in a vacuum. Instead, being a certain kind of smoker is itself something which is only possible or meaningful under certain social, cultural, economic and historical conditions. These include, but are not restricted to, the activities of governments, global stock market flows, patterns of socio-economic development and inequality, the tobacco industry, tobacco control, etc., and the manner in which these elements interact.

The smoker as non-agent

The concept of ‘nudging’ in public health draws on a different models of the person. Nudging involves manipulating the environment to provide — or remove — stimuli in order to prompt people to behave in healthier ways. Examples might include the removal of ‘tobacco walls’ from retail outlets or legislative changes such as the ban on smoking in indoor public places. The evidence suggests that such practices can be effective (Hargeaves et al. 2010, Marteau et al. 2011) but the model of human nature on which they are based is different to that of the rational, agentive human being who can be persuaded by appeals to the intellect or the emotions. This schema imagines smoking persons as devoid of agency. Rather the smoking person becomes a Pavlovian automaton, a view supported by some psychopharmacological research on dependency (Hogarth 2011). In this framework, smokers’ behaviour is fuelled by their inherent impulsivity and need for instant gratification.

The idea of the smoker as addict fits this conception. The rhetoric here states that addictive substances contained in tobacco imbue the desire to smoke and compel the action of smoking, with the smoker following an impulse which is ordered from within her own body but by an agency other than her own. In a curious twist of paradigmatic frames, tobacco (or, more accurately, the addictive substances in tobacco, such as nicotine) function as an agent or actant in a Latourian sense (Latour 2005, p. 107). The tobacco control fight here is against the addictive substance, a battle that takes place within the body of the smoker but, again, mostly without her conscious awareness: the idea is, as before, to expel the material actant from within and thereafter keep it firmly excluded from the non-agentive body. In this vision, the smoker is seen as a victim of either internal or external forces which, as the material and immaterial causes of the smoking misbehaviour, are the real agents.

Once again this model of the smoking person fails to account for and explain a large proportion of real smoking practices, such as social or secret smoking (Thomson et al. 2009b) or cycles of quitting and re-starting. And, as before, there are political and economic consequences deriving from considering smoking persons as non-agents: tobacco consumption can then be comfortably fitted within the epidemic model for both research and practice purposes, and certain forms of public health interventions are reinforced and reified, even if their effectiveness is limited (Mair and Kierans 2007).

The myth of the stable ‘core’ person

Underlying these conceptions of the person in smoking cessation research and practice, that of the agentive, rational decision-maker and the non-agentive automaton at the mercy of external forces beyond her control, is a model of a unitary being constituted by a stable core and a movable periphery. What the interventions aim to address are less the person but their problem behaviour: an appendage of the stable core person (Mair 2011). Research articles abound with beings who are variously classified as men, women, young, old, middle class, manual workers, imprisoned, mentally ill, white or from an ethnic minority. All these beings possess, extraneous to their ‘core’, immaterial and mutable appendages in the form of values, ways of thinking and, most importantly, behaviour. These epiphenomena are regarded as separate and separable from the being of a person, things that can and, in some cases, should be changed. They are attributes put there in the first place, somehow artificially, by others in the form of social norms, peer pressure or media messages. Or else, and sometimes simultaneously, they result from an inner taint or weakness — impulsivity, psychiatric problems, addictions or even a deviant nature. What follows is a logic of addition and subtraction: something added can also be taken away. Since it is not intrinsically of the person, it can be removed. The individual remains, but with the undesirable attribute discarded.


Critical tobacco-related research

All models of the smoking person discussed above provide the rationale for different kinds of anti-smoking campaigns, but all have come in for criticism from social sciences and humanities scholars who conceive of human beings differently. Their work challenges the notion of individuals as static, stable entities, either in control of or subject to their behaviours, but always, potentially, able to expunge them without compromising their essential selves. They make it evident that alternative types of research — away from the tobacco control model — are necessary if we are to understand not only the way in which persons are constituted and what makes them tick, but also what it is in the experience of smoking that makes it so attractive, meaningful and persistent, and what wider interpersonal, relational, social and cultural significances are brought about by the act of smoking. In some ethnographic work, for example, people describe cigarettes as being like friends or companions accompanying them through life in the absence of less reliable (human) friends. In a study carried out in Rio de Janeiro one woman described the cigarette as:

… the best and worst friend you can have. … he is the best because he is with you when you are sad, when you're happy, when you have insomnia […] It is worse because it kills you, but it causes great pleasure. (Trotta Borges and Simoes-Barboas 2008)

Hargreaves et al. (2010) found similar language in their study of the effects of the legislation on smoking in public places in England, noting how some smokers describe their relationships with cigarettes: ‘So everytime you get stressed […] I'll have a cigarette. It's always a way out, so I see that as like a partner …’. Hilary Graham's pioneering work in this field has traced the importance of smoking in the lives of women in stressful situations such as caring for children in low income families. Smoking is ‘an excuse to stop for 5 minutes’, in the words of one mother, ‘a moment of self caring which, unlike a cup of tea of coffee, needed no preparation’ (Graham 1987).

Thompson et al. (2009b) studied smokers in New Zealand and uncovered subtleties of identity which take us much further than the traditional distinction between ‘smoker’ and ‘non-smoker’ describing how individuals can shift in and out of such identities. One ‘ex-smoker’ (‘Diane’) describes how, having given up, she temporarily returned to it while drunk. Having bought some cigarettes from a woman in a restaurant, she states: ‘I was conscious of the fact that I could show her I could really smoke so I was full draw-back, coming out of my nose, the whole thing’. This description of the act of smoking gives some sense of its embodied pleasure, a theme also picked up by Dennis’ (2011) respondents. ‘Megan’ extends the sensuality of smoking for herself into flirtation, ‘If I'm interested [in a man] I like to blow my smoke up around the side of his face, like a caress’.

There are recurring themes throughout this empirical work on the lives people who smoke: cigarettes help women ‘cope’ under stress, provide time out and space in difficult lives, supply companionship when none is available; are a source of enjoyment, of sensual pleasure; they constitute identities — coolness, glamour (Willms 1991), being one with the crowd; but they also precipitate guilt about failing to stop, disgust at the smelliness of the habit and its unhealthiness. These researchers all note the paradox for smokers: that smoking ‘works to promote … well-being while threatening their physical health’ (Graham 1987). The smoking person here is the result of a complex interplay of relationships — with others and with cigarettes — involving sensation, emotion and rational decision-making that combine in different configurations at different times and result in smoking or non-smoking acts.

Social science thus critiques the narrow view that public health has taken of the smoking person and investigates the meanings that smoking has for individuals, the embodied experience and the way in which it helps to constitute the many shifts in identity that people inhabit. This work critiques the construction of smoking subjects and behaviours which then provide the rationale and justification for public health and tobacco control actions. Following Mair and Kieran's (2007) call for a diversification of tobacco-related research, however, we would like to suggest the inclusion of other sources of knowledge about people who smoke and about the worlds they make and inhabit in the company of tobacco. We propose that humanities have much to offer a more empathetic, open-ended understanding of smoking persons, one which is also free from moral judgements and from the political and economic imperatives of tobacco control.


Understanding the smoking person: what other views may help?

The humanities, like the social sciences are interested in representing meaning, but, particularly in the form of the literary and creative arts, they have the advantage of being able to give voice to aspects of existence that might otherwise be inexpressible. For example, in the exchanges between GPs and patients recorded by Pilnick and Coleman (2003), smokers often appear to struggle to put into words what smoking means for them. As we have seen, a theme that keeps cropping up throughout the studies discussed above is the idea of ‘coping’. ‘Coping’ may have become a kind of shorthand for the complex interdependence between human beings and cigarettes which is played out in some of the other themes we discussed. It hides feelings and relationships that may be inexpressible because most of us — those who smoke and those who research them — lack the language and reflexivity necessary to give these relations and feelings a coherent voice. In clinical settings, respondents are very familiar with framing narratives for presenting the stories of their illness or health behaviour (Montgomery Hunter 1991, p. 128). Likewise, in a research context, responses may be put into a familiar or expected language which only approximates to the way things are for the person concerned. Other ways of expressing the meaning of smoking for individuals, such as through the language of pleasure or aesthetics, may thus be stifled in clinical or health research contexts because of such expectations and, as Bunton and Coveney (2011) point out, because the aesthetic pleasure of smoking is unacknowledged, poorly understood or derided.

If we were to frame the experience of smoking more widely within an embodied existence that recognises the boundary between our bodies and the outside world (Radcliffe 2008), we might come to a deeper understanding of the idea of smoking as ‘coping’. The lungs represent a space within the body that is bounded but nevertheless connected to the outside world by the spontaneous activity of breathing (Katz 1999). Drawing in smoke and then exhaling it makes that connection between inside and outside visible. For those for whom the world is a difficult place, smoking can convey some symbolic control over the connection between the body and the world. Smoking can contain and stifle that connection, allowing the person struggling with external pressures to attain at least vicarious protection from the hostile space of the world.2

This level of understanding can be accessed via the kind of ethnographic work described in the preceding section (Dennis 2011). Such empirical work pays attention to the symbolic meaning of smoking, how it delineates boundaries between the body and the external world; and how it emphasises the importance of relationships with things and context. These themes are also clearly evident in the work of literary writers of fiction and non-fiction. In these works, experience can be more broadly framed within a lifeworld that is not confined to questions about smoking, and insights may be accessed from both internal and external perspectives. In this context, the existential can be voiced alongside the practical in the lives of characters portrayed.

The way smoking draws attention to the relationship between the spaces of the body and external space is well represented in the English playwright Simon Gray's series of literary diaries about his life and writing. In The Smoking Diaries (Gray 2008a), he describes his memories of starting smoking:

…our smoking was exhilaratingly furtive, the deep, dark, swirling pleasures of the smoke being sucked into fresh, pink, welcoming lungs, it took me just three or four cigarettes to acquire the habit and you know there are still moments now when I catch more than a memory of the first suckings-in, the slow leakings-out when the smoke seems to fill the nostril with far more than the experience of itself, and I regret the hundreds or thousands of cigarettes that I never experienced, inhaled and exhaled without noticing …(p. 58).

Unlike the case of the ‘coping’ smoker, who may see smoking as confining experience, Gray here revels in the widening of experience inherent in the act of smoking. The quote from the lapsed quitter (‘Diane’) above (Thompson et al. 2009b) gives voice to similar ecstasies, but the account of a skilled writer takes us further. Gray is revelling in the feeling of smoke in the body's internal space — ‘far more than the experience of itself’ — and he draws attention to the physical sensual pleasure of the act of smoking and also to the way in which smoking enhances the embodied experience of inhalation and exhalation, normally carried out without conscious awareness.

Gray's experience — and failure to quit throughout his life — parallels that of the fictional Zeno Costini in Zeno's Conscience (Svevo 2002). Zeno's account of first starting to smoke is similarly furtive and intense. Having stolen some of his father's cigars he carries them off to smoke in secret:

At the very moment I grabbed them I was overcome with a shudder of revulsion, knowing how sick they would make me. Then I smoked them until my brow was drenched in cold sweat and my stomach was in knots. (p. 8)

Attempts to give up are fruitless. As a result of a fever and sore throat his doctor advises ‘… absolute abstention from smoking. I remember that word, absolute! It wounded me, and my fever coloured it. A great void, and nothing to help me resist the enormous pressure immediately around a void’ (p. 10). In an attempt to comply he allows himself ‘one last cigarette’ (a recurrent theme in the novel): ‘I lit a cigarette and felt immediately released from the uneasiness’ (p. 10).

Pattison and Heath (2010) note this same pattern in the life of Gray (2008b) who devotes one volume of his diaries to ‘the last cigarette’. He does not achieve abstinence, but manages to cut down. For Gray ‘smoking is an integral part of his identity’ (Pattison and Heath 2010). His smoking is intimately associated with his embodied existence as a writer. He recounts to his readers the process by which his diary is being produced:

All of the above was written — is being written — onto a yellow pad by a Cross ballpoint pen (pleasantly heavy) held, in the classic handwriter's grip, between the thumb and the forefinger of my right hand […] in my left hand, held between the two middle fingers in the classic smoker's grip, is a cigarette. But of course I smoke with my right hand when it's not busy with a pen. (Gray 2008a, p. 54)

The works of creative artists are full of such accounts of smoking, allowing the nonsmoking reader a rich sense of the embodied pleasures of the habit. ‘I love stroking this lovely tube of delight’, says the playwright Dennis Potter in his final interview before his death from pancreatic cancer (Bragg 2007). His sensuous enjoyment is echoed in the following passage from the autobiography of Spanish filmmaker Luis Buñuel: ‘… I love to touch the pack in my pocket, open it, savor the feel of the cigarette between my fingers, the paper on my lips, the taste of tobacco on the tongue’ (Buñuel, quoted in Walton 2000, p. 181). It is as if Buñuel is speaking of a lover, so intense is the quality of his feeling for the cigarette and the experience of smoking.

As in the case of Gray's description of his first cigarette, these accounts may enhance our insights into the kinds of relationships with cigarettes more obliquely conveyed in research interviews with smokers. The notion of cigarette as ‘friend’ or ‘companion’ seems more intelligable if we are able to access the feelings from which these descriptions arise. Klein (1993) examines these feelings in his book, Cigarettes are Sublime. Despite the allure of the habit he describes, Klein managed to quit while writing it. Klein summarises this allure:

The moment of taking a cigarette allows one to open a parenthesis in the time of ordinary experience, a space and a time of heightened attention that give rise to a feeling of transcendence, evoked through the ritual of fire, smoke, cinder connecting hand, lungs, breath and mouth. (p. 16)

What we are arguing here is that literary accounts, whether fictional or non-fictional, cover the same kind of ground as has more recently been opened up by qualitative researchers, and that these accounts contribute important additional insights into the experience of smokers. Literary accounts can represent those aspects of the smoking person that reflect life lived imaginatively, sensually, joyfully, motivated and influenced by tactile pleasures, beliefs (that may be irrational), enchantment and desire. In these contexts, smoking and its meanings can be brought vividly to life in ways that are not readily accessible to the sciences or social sciences. Of course, such accounts cannot function as ‘evidence’ in the same way as empirical work. They cannot be read as representing experience in the way ethnography does. On the other hand, they may allude to smoking as a signifier as well as something signified. Smoking is often used in film, for example, as a signifier of the sexually available, vampish woman (Isenberg 2004, p. 248) and at other times to denote the maverick outsider (Sigourney Weaver in Avatar). This semiotic function only works, of course, if it resonates in the minds of the audience and the cultural signifiers ground smoking appropriately in time and space (a claim that is strained in the case of Avatar). Care needs to be taken in interpreting smoking in these cultural contexts.

What we are championing here is a different kind of knowledge to that derived empirically. The novelist David Lodge, describes this knowledge as ‘complementary to scientific knowledge’. He goes on: ‘The philosopher Nicholas Maxwell calls this kind of knowledge “personalistic,” and argues that it must be combined with scientific knowledge if we are to attain true “wisdom” (Lodge 2002, p. 16). That knowledge, represented within the imagined world of the novel or in the heightened reality of literary biography, as Lodge suggests, opens the reader's perception and experience to other modes of being by speaking directly to a consciousness unframed by distancing methodologies.


The pragmatic need for ‘critical’ public health

Bringing together these two modes of understanding can be revealing of the complexity with which human beings interact with the things, spaces and people of their world. As Good (1990, p. 122), relating these ideas explicity to medicine, asserts:

The scientific world is only one of several worlds or ‘subuniverses’ in which we live, worlds which include those of religious experience, of dreams and fantasies, or music and arts, and of the ‘common sense’ reality which is paramount in much of our lives. These are not simply forms of individual experience, but diverse worlds, with distinctive objects, symbolic forms, social practices, and modes of experience.

William James, a philosopher, addressed the challenge of different ways of thinking about human nature in his description of pragmatism (the philosophical tradition with which he is associated) as a mediating philosophy. His point is that whereas our society is trained and expected to respond rationally to empirical and scientifically generated facts and information (James 1929, p. 15) — namely Common Sense About Smoking — our actual lives and sense of being in the world are experienced differently. The idea of having a relationship with a cigarette, or the apparently irrational switching, according to context, from non-smoking person to smoker makes sense in these pragmatic terms. In his writings, James (1929, p. 13) does not dismiss medical materialism but he insists on the centrality of other sorts of experiences, such as the emotional and spiritual, which are essential to what it means to be human.

Applying this to a particularly pressing problem in UK tobacco control it seems clear, from a recent review of qualitative research examining smoking in pregnancy, that many women suffer from a sense of emotional disruption at this time in their lives (Graham et al. 2011). Graham's findings present a group of women dealing with a major change in their sense of being (pregnancy) having also to cope with guilt, confusion and stress because of pressures on them to quit smoking. Many pregnant women report coercion from partners who do not feel the need to quit themselves, or struggle with the sense that it is their ‘only pleasure’ during this difficult time (Sims and Smith 1983). Others are caught in a constant stressful carousel of being a smoker, attempting to become a non-smoker and then relapsing back to smoking. The result is a kind of ontonlogical strife, such as that described by Sartre (2003, p. 617) when he attempted to quit:

… it seemed to me that in giving up smoking I was going to strip the film of its interest, the evening meal of its savor, the morning work of its fresh animation. Whatever unexpected happening was going to meet my eye, it seemed to me that it was fundamentally impoverished from the moment that I could not welcome it while smoking. To-be-capable-of-being-met-by-me-smoking: such was the concrete quality which had been spread over everything. It seemed to me that I was going to snatch it away from everything and that in the midst of this universal impoverishment, life was not so worth living.

Sociologists Bowker and Leigh Star (1999, p. 27) refer to this sense of strife or impoverishment as ‘torque’; in their words, ‘a twisting of timelines that pull at each other’ resulting in a sense of unease and of difficulty in finding one's place in the world. Leigh Star and Bowker developed this idea by examining the shift of being from the stable category of ‘ill’ to the category of ‘well’ in the context of the tuberculosis sanatorium in Thomas Mann's novel, The Magic Mountain. The shift may be ultimately desirable, but it is none the less difficult and involves a disruption of being. The literary context from which the idea of torque derives is important. It is only by exploring disease against this background that Bowker and Leigh Star are able to foreground the ‘out of time’ experience of the sanatorium. As Mann himself commented in the afterword to his novel: ‘the story practices a hermetical magic, a temporal distortion of perspective reminding one of certain abnormal and transcendental experiences in actual life’ (Mann quoted in Bowker and Leigh Star 1999, p. 186).

The literary examination and development of the idea of ‘torque’ enables us to make more sense of the unease and stress felt by women who feel forced to undergo a shift of being during pregnancy. It also suggests the possibility of further empirical research that might compare the well-being and pregnancy outcomes of women who continue to smoke those few ‘essential’ cigarettes during pregnancy unencumbered by guilt and efforts to quit, against those women who constantly strive to achieve non-smoker status. At the very least, accounts of attempts to quit — by the women smokers and by Sartre himself — may be best understood against the background of literary sources in which the sense of ‘being’ as a smoker is given its fullest explication.

Here, then, is where literary accounts in tandem with the social sciences might lead to more effective approaches to tackling the problem of smoking. If we accept that smoking is for many constitutive of personhood, identity and a source of pleasure, as well as fully embodied and part of how they function as physical beings in connection with the everyday things of the world, we might envisage more nuanced ways of supporting cessation for individuals, and encourage more humane, less stigmatising attitudes towards those who smoke. More controversially, we might even accept that individual smokers might sometimes be better left alone, with attention focussed instead on tobacco companies and the fiscal policies of national governments.


Conclusion

In this article, while acknowledging advances made in social science research to elicit and understand the experience of smokers, we have explored what the humanities have to add to how we conceptualise that experience. There is a need to develop a more expansive understanding of human beings located culturally, historically, socially and existentially; and to provide a full range of accounts of these beings that link social sciences and humanities disciplines more closely. In addition, for researchers in the field of critical public health, it is important not just to critique but to offer practical applications of our extended understanding. In the parallel developing discipline of critical neuroscience, a similar point is made by Choudhury and Slaby (2012):

Preserving and integrating the forms of expertise and the discourses about human nature and the human lifeworld that philosophy, anthropology, sociology, history, and other humanities disciplines provide, is necessary in the face of neuroscience's expansion and unquestioned cultural and institutional capital. This will ultimately benefit neuroscience itself as it may be productively aligned with — instead of opposed to -those more traditional canons of knowledge that still, and rightly we believe, form the foundations of our scientific, cultural, and political self-understanding. (p. 3)

In this passage, ‘neuroscience’ can productively be replaced by ‘public health’. As a community of researchers, we need to use our understanding to work alongside public health in developing approaches that better respect a more complete view of human nature.

As Eliot's (1974) poem, East Coker, suggests, there may be limitations to the ‘knowledge derived from [empirical] experience’, and benefits to be gained by entering the imaginative worlds invoked in literature. Without rejecting the legitimate accounts of biomedicine and the understanding generated by scientific and social scientific investigation, we can insist on the importance of integrating ‘evidence’ generated by non-scientific means — ‘risking enchantment’ by experiencing the existential in accounts of being a smoker. Such accounts bring with them a sense of ‘whats-it's-like’-ness that can be further enhanced by an understanding of the historical and pragmatic importance of smoking in people's lives. We think that working alongside these different perspectives will allow new approaches to research in public health and in the humanities; and that this integration has the potential to inspire new ways of supporting efforts in tobacco control.


Notes Notes

1.This report, according to Berridge (2007, p. 16), ‘was the harbinger of a new media-based role for medicine’ in which science, including epidemiology, was put to work explaining the dangers of smoking to a receptive public.

2.This interpretation has been verified anecdotally by a lapsed ex-smoker who resumed the habit during a relationship breakdown.

Acknowledgements

This work was supported by the Wellcome Trust (Grant number WT 086049).


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Article Categories:
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Keywords: smoking, medical humanities, humanities, public health, human nature.

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