Using discursive approaches to examine the utility and functions of language in public health and health promotion: highlighting social constructions of e-cigarettes

ABSTRACT

This article uses discursive approaches to examine the utility and functions of language in public health, focusing on social constructions of e-cigarettes. Due to the ambiguity surrounding the use of e-cigarettes, understanding may be negotiated collaboratively through co-construction in talk. Ten participants, three men and seven women aged 26–47 years, took part in two focus groups in Manchester, UK, where they discussed e-cigarettes. Data were analysed using blended discourse analysis, with a view to identifying dominant repertoires used by speakers. Participants drew from two discursive frameworks to communicate perceptions of e-cigarettes: (1) uncertainty and risk and (2) the social acceptability and stigma spectrum. The ambiguity surrounding e-cigarettes was reflected in the linguistic devices used in talk. This article demonstrates the value of drawing on discourse analysis to better understand the impact of health-related communication by providing insight into how existing messages are interpreted, co-constructed, and assigned meaning through shared interactions.

KEYWORDS:

• Health promotion
• discourse analysis
• discursive psychology
• social constructions
• e-cigarettes

Introduction

E-cigarettes are battery-powered devices which aim to simulate the experience of cigarette smoking by heating a liquid into an aerosol that can be inhaled; the liquid can contain nicotine, although some can be nicotine-free (Mathur & Depmsey, 2018). Public Health England (PHE) claims that e-cigarettes are 95% less harmful than cigarettes (McNeill et al., 2022); however, although it is emphasised that vaping poses only a small fraction of the risks of smoking, this does not mean vaping is risk-free, particularly for people who have never smoked (McNeill et al., 2022). However, some still contest these figures (Eissenberg et al., 2020; Glantz & Bareham, 2018).

E-cigarette use is a topic of debate, creating a quandary across many disciplines and disrupting existing views on tobacco harm reduction (THR) strategies. There is disagreement regarding their efficacy as smoking cessation products (Leduc & Quiox, 2015), use by minors and the gateway effect (Etter, 2017; Farsalinos & Gillman, 2018), the role of flavours (Farsalinos & Gillman, 2018) and safety of the second-hand vapour (Visser et al., 2019). The impact of e-cigarettes on smoking inequalities is also unclear (Hartwell et al., 2016). Exaggerated media stories have also polarised the views of the public, creating uncertainty, feelings of apprehension and misunderstanding toward e-cigarettes (Harrell et al., 2019; Wilson et al., 2020, 2021).

These tensions may be because e-cigarettes have enabled the formation of a new arena in the field of nicotine dependency; functioning as a bridge that links the two different forms of nicotine (i.e. medicinal and recreational), they may act as translational boundary objects enabling people with varying opinions of nicotine, smoking, and e-cigarettes to agree on similar meanings without consensus, and facilitating acceptance of harm reduction practices (Tamimi, 2018). Contributing further to uncertainty, e-cigarettes have entered national and international public health discussion at a time of increasing ‘post-truth’ discourse where expert science and opinion is increasingly doubted (Lucherini, 2021).

The lack of certainty in expertise (Lucherini, 2021) provides an opportunity to consider alternative methods to understand how health-related communication and messaging is being interpreted. Due to the ambiguity surrounding the use of e-cigarettes, understanding may therefore be negotiated collaboratively through co-construction in talk during social interaction; these interactions appear to be influential in shaping norms surrounding e-cigarettes, playing a complex and unique role in the way individuals make decisions regarding them (Katz et al., 2019; Wilson et al., 2020).

This paper uses a small corpus of data to illustrate the value of drawing on discursive approaches to generate understandings that are useful for health promotion, using co-constructed accounts of e-cigarettes. Discursively examining how individuals co-construct e-cigarettes may allow reflection on how policy debates and public health messaging are interpreted and illuminate the norms that operate in health communication between health professionals and lay people.

Method

Design

Heterogeneous focus groups were utilised as they are particularly reflective of ‘real life’ situations whereby groups of people would be likely to be genuinely heterogeneous in their e-cigarette/smoking status. Heterogeneous groups enable the exploration of multiple perspectives at once, providing ’live’ insights into how health promotion messages are interpreted and potentially ‘re-constructed’, identifying both diverse individual interpretations and prevailing social norms which influence accounts. They also provided an opportunity to gain insight into how consensus and/or disagreement on health-related topics in group discussions are formulated, which can lead to an in-depth discussion as participants defend and negotiate their experiences.

Recruitment and participants

Participants were recruited using opportunity sampling, which recruits participants from the target population who are available at the time and are willing to take part. Participants were identified by responding to the recruitment media. They had to be fluent in English and over the age of 18 years, but no other inclusion criteria were applied. In total there were 10 participants: three men and seven women. Age ranged between 26 and 47 years. The participants were heterogeneous in terms of their e-cigarette/smoking status (each participants’ smoking status is reported in the exchanges). The decision to include non-smokers and non-vapers within the sample was to be reflective of everyday life whereby people in day-to-day conversations are likely to be heterogeneous in their e-cigarette/smoking status. This decision also allows for the consideration of the impact of social context on e-cigarette-related behaviours, as although this demographic may not use the devices themselves, research has demonstrated the impact of social influence on smoking-related behaviours and e-cigarette behaviours (Amin et al., 2019). This approach shifts the lens from individual attribution and responsibility to the impact of how wider societal structures contribute to dominant narratives. Participants were allocated to each group on a first-come-first-serve basis.

Procedure

Ethical approval was obtained from Manchester Metropolitan University’s ethics committee (Reference Number: 11915). Focus Groups took place in Manchester, UK, between March 2020-May 2020. The first group was conducted face-to-face and the second was online (due to covid restrictions). The first author conducted both focus groups. Before starting the audio recording, participants were informed of the ground rules and reminded of the key elements of the research. The discussions were recorded using a Dictaphone. Participants were first asked to introduce themselves by sharing their chosen pseudonym and their experience with e-cigarettes. Both discussions concluded with the researcher asking some reflective questions about the process of the discussion. Sessions lasted between 45 and 73 minutes and were closed when the conversation dried up naturally. Following the completion of the discussion, participants were thanked and de-briefed.

Analysis

A blended discourse analysis (Potter, 1996) was used to analyse the data. This analysis was deemed appropriate because analysing talk can facilitate the understanding of how objects are positioned within wider societal discourse. This approach to analysis sees talk as a form of action devised for specific contexts (Potter, 1996). Language is perceived not just as a neutral communication tool that accurately depicts reality, but instead, it constructs and defines social life, where people assign meaning to real-world phenomena. This can be particularly insightful when exploring how people use language to discuss contemporary debates within public health and health promotion. Discursively exploring linguistic interactions and language performance between members of the public can provide insight into how such issues are talked about and constructed. These nuances of co-construction in conversation may cast light on how current health-related messages are interpreted.

The analysis was informed by features of discursive psychology (Edwards & Potter, 2000), which provided theoretical grounding as the analysis is rooted in the action orientation of talk. There was also a focus on how speakers use language to manage their stake and present their account as credible (Edwards & Potter, 2000). The analysis followed three steps (Edwards & Potter, 2000): (1) locating central themes that were discussed in talk, (2) focusing on the discursive practices, and (3) exploring how participants used language to co-construct accounts.

Results and discussion

The analysis proposes two frameworks that participants draw from to communicate their perceptions of e-cigarettes. These include (1) uncertainty and risk and (2) social acceptability and stigma spectrum.

Uncertainty and risk

E-cigarettes were discussed as ‘healthier’ and ‘safer’ than tobacco cigarettes. However, at the root of this discourse was the claim that there was still a significant amount unknown about them (‘it needs to be clearer’, ‘we don’t know’).

[FG2 Lines 171–190]

Dominic (dual):

General lack of education on it, kind of

Sophia (non-vaper/smoker):

Yeah and I think as well like there was a study that came out a while ago that was like if you use them, they give you popcorn lung and –

Valentina (dual):

[Yeah, I saw that]

Sophia (non-vaper/smoker):

It’s like what is popcorn lung? Like, what is that? What does that mean? It sounds ridiculous but at least, it’s ridiculous, but at least with cancer you know what you are getting, and at least with COPD, you know what you are getting, with popcorn lung it’s like, what is that? It’s like popcorn sounds cute, it doesn’t sound like it’s a problem, do you know what I mean? Like I feel like that doesn’t, probably doesn’t help like in terms of contributing to the narrative that they are harmless compared to cigarettes even though there is a health risk associated with it, it’s hard to like I dunno for me, I find that hard to put into context because I don’t know what it is

Valentina (dual):

[Yeah]

Simone (dual):

I think people are happily oblivious until they are shown like the hard, the true hard facts about things, if you just kind of slightly hint toward something being bad, people aren’t going to take that seriously

Valentina (dual):

[And I do think as well]

Dominic (dual):

[We don’t know what the worst-case scenario is] like by the way this is how bad it could get, or you might be fine

Valentina (dual):

Yeah

Sophia (non-vaper/non-smoker):

I think cos it’s definitely it’s the lesser of two evils as well, I think to some extent whatever you say about e-cigs and even if that is backed up with good solid data, if it’s not as bad as cigarettes, y’know people are always gonna be like y’know it’s the lesser of two evils

The use of the modifier ‘kind of’ by Dominic [dual user, FG2] implies impartiality, softening the sentence so it does not appear too exact, which indicates his uncertainty in the accuracy of his own account. Note the use of a three-part list of rhetorical questions by Sophia [non-vaper/non-smoker, FG2], ‘What is popcorn lung? Like, like what is that? What does that mean?’. One of the most held concerns regarding e-cigarettes is that they could cause ‘popcorn lung’¹(Public Health England [PHE], 2018). Listing provides speakers with a means to position themselves in relation to items on the list, also known as an ‘orientated-to-procedure’ (Jefferson, 1991). However, the function of listing in the form of rhetorical questions presents an interesting discursive technique. Although the questions could appear information seeking, the repetition of similar questions emphasises the notion of uncertainty.

Rhetorical questions exemplify utterances whereby the form does not match the function, by mimicking the structure of a question but with the force of an assertation. For this reason, it is generally assumed that they neither truly seek information nor answers and therefore have been previously defined as biased assertions (Sadock, 1971), especially when they have seemingly obvious or similar answers. It appears that Sophia [non-vaper/non-smoker, FG2] was not seeking an answer, as she continued to speak. This discursive strategy was used to emphasise her point about the expansive questions about popcorn lung and subsequently e-cigarettes.

Sophia also continues to repeat ‘at least’ and ‘you know what you are getting’ when discussing smoking-related illnesses such as cancer or COPD. This emphasises that although smoking-related illnesses can be fatal, it is better to partake in an activity (smoking) where the potential consequences are better understood, than an alternative activity (e-cigarette use) where the consequences are uncertain. Uncertainties therefore impact risk assessments and decision-making around e-cigarettes. She later goes on to state ‘definitely the lesser of two evils’ [Sophia, non-vaper/non-smoker, FG2], contradicting her previous assertation, presenting an ideological dilemma. The word ‘evil’ has no positive connotations, as by definition it means the absence of good. It could be argued this reflects Sophia’s position as a non-vaper/non-smoker as she cannot see the potential of e-cigarettes in regard to tobacco harm reduction.

Simone [dual user, FG2] demonstrates interest exposure, when she states that ‘people’ are happily oblivious and do not take things seriously. This change in footing (Goffman, 1981) presents a change in the alignment she takes to herself and the others, by negating any personal criticism and stating that this element of her account is not driven by personal experience. The use of the word ‘people’ instead of ‘I’ makes the speaker (Simone) appear more objective, unbiased, and trustworthy. Sophia [non vaper/non-smoker, FG2] also uses this technique in the extract above. The symbolic panoptic gaze (Foucault, 1975) can be linked Simone’s talk about the judgement of others. Her comments allow her to regulate and vocalise how her practices are in line with societal norms, managing her stake in the process (Potter, 1996).

Simone presents uncertainty regarding how e-cigarettes will be perceived and therefore does not make any claims that may be viewed as unacceptable by the group. There are also elements of blame in Simone’s talk, she blames a particular group (‘people’) whilst elevating herself, which presents another ideological dilemma, as in alternative extracts she admitted that she is also unaware of certain elements of e-cigarettes. The use of discourse analysis has provided a unique insight here, as it demonstrates what Simone is doing with what she is saying, which is different to just what she is saying. Simone’s word choices indicate nuanced and perhaps unconscious concerns regarding stigmatisation and health-related behaviours.

Dominic [dual user, FG2] states ‘we don’t know what the worst-case scenario is’. The use of the pronoun ‘we’ presents an engagement strategy by proposing a collective perspective on this issue of general uncertainty. It implies a sense of commonality with the other participants, a common identity that unites those categorised. The action being performed by Dominic’s choice of pronouns is just as meaningful as the words themselves, further illustrating the value of using discursive approaches when exploring health-related issues.

This has also been demonstrated in the extract below by Mary [smoker, FG1].

[FG1 Lines 247–259]

Mary (smoker):

[…] cigarettes are becoming less socially acceptable now, I think it is far more OK to vape that it is to smoke

Poppy (dual):

and I don’t think kids realise the risk of vaping whereas they do with smoking, y’know, so they will go on to a vape thinking it just looks really cool and not realising that it’s just as addictive really, and I’ll be honest, I’ve noticed the difference. So, I had pancreatitis and when I smoked it used to cause massive pain to me, and since I’ve stopped it and even when I was using the vaper pipe it was the same, it had the same effect on me I was in pain all the time, and now, touch wood, since I’ve stopped using the vape, I’m not in any pain at all with my stomach. So, the fact that it was doing that to me tells you, it’s not … it’s not doing good things

Mary (smoker):

I think it needs the same health warnings that … or we need to know what the health implications are, like smoking has got all the nasty pictures and all the health warnings and as a smoker I just ignore them because -

Barbara (ex-smoker):

Well, you don’t even think they are going to happen to you, do you?

Poppy uses extreme case formulations, stating that she was in pain ‘all the time’ when using e-cigarettes, but now she has stopped, she is not in pain ‘at all’ (minimising), shedding a negative light on e-cigarettes and solidifying her position on them. However, she then goes on to use the expression ‘touch wood’ which is often used superstitiously to avert the possibility that something just mentioned (if bad) might not occur, or (if good) might occur. In this case, diagnoses and outcomes are related to luck rather than a consequence of health-related behaviours.

The notion that illness or diagnoses are unpredictable is further emphasised when Barbara [ex-smoker, FG1] states ‘well you don’t even think they are going to happen to you, do you?’, implying that although health warnings are clear, it is still common for others to ignore and/or not believe warnings. Barbara defends her stake, using ‘you’ instead of ‘I’, positioning herself as separate from others who ignore health warnings related to smoking; this could also be related to stigma surrounding smoking. What Barbara is doing with what she is saying, her word choices, indicate nuanced concerns regarding stigmatisation and health-related behaviours which are not reflected directly in the content of what she is saying.

In an alternative extract, Mary [smoker, FG1] states, ‘we don’t really know’, implying the collective response of uncertainty for the whole group, as previously discussed. It appears throughout both extracts that the word ‘we’ was used when participants made statements about not knowing/needing more information. Yet, in alternative extracts, phrases such as ‘for me personally’ [Sophia, non-vaper/smoker, FG2] or ‘at least that’s my relationship with it’ [Dominic, dual, FG2] were used regularly to highlight an understanding that experiences varied due to the heterogeneous nature of the group members. The individual stances, potentially diverting from other views, are also softened using these phrases, as participants made it clear that they are not discrediting or judging others’ experience. So, it is telling that ‘we’ was used when discussing uncertainty. The active voicing strategy (Hutchby & Wooffitt, 1998) used by Barbara [ex-smoker, FG1] when she states, ‘they said’ contributes to ambiguity, as she cannot provide the details of ‘who said what’, demonstrating the perceived inauthenticity of e-cigarette information sources.

Discourse markers (y’know, I mean) are used frequently throughout both discussions, emphasising uncertainty. These types of markers play a major role in progressing knowledge about the world. Speakers use ‘y’know’ to enlist hearer agreement, confirmation, and affirmation of the receipt of information (Schiffrin, 1987). Seeking confirmation from others is an indication of lack of certainty. Confirmation checks (isn’t it? hasn’t it?) were also used throughout both discussions. Confirmation checks ask the hearer to concur that the first statement is true. Sometimes, it is obvious the statement is true, and these devices can also be used to invite the hearer to continue the conversation. In this instance, they were used to expand on the co-constructed knowledge of e-cigarettes. Long (1980) claims confirmation checks are often used to seek confirmation that the utterance has been correctly understood or heard by the speaker. This contributes to the underlying sense of uncertainty regarding e-cigarettes, as speakers are keen to develop their understanding by conferring with others in the group.

Hedging, the use of conditionals (‘it might be much worse than we think’ [Simone, dual user, FG2]) and modifiers ‘they probably wouldn’t think to use them’ [Mary, smoker, FG1]), is used throughout both discussions. Hedging is a negative politeness strategy which marks the statement as provisional, awaiting acceptance by the hearers and does not impose certainties. Hedges are usually verbal and adverbial expressions (may, could, perhaps), used in talk when dealing with degrees of probability. They serve as an interactive bridge between interpretation and initial propositional information (Gribanova & Gaidukova, 2019). The use of hedges by the speakers implies lack of precision, avoidance of further questions, or reluctance to self-disclose (Lakoff, 1972). This technique allows participants to deflect the power away from themselves as they do not want to be perceived as responsible for making bold statements.

In a summarising point, toward the end of Focus Group 2, Dominic [dual, FG2] states ‘I think it’s even established that most of us here use e-cigs daily and it’s actually quite frightening that none of us know really anything about them’. The use of the extreme case formulations that ‘none’ of the group knows ‘anything’ firstly presents the absolute condition that no-one knows anything, which itself is contradictory as throughout the discussion each member contributed to the discussion and demonstrated some element of awareness. Thus, what is noticed throughout both discussions is a co-constructed account of an ideological dilemma: the acceptance that e-cigarettes are healthier and a more socially acceptable means of smoking, but also that there is not enough information about them. This echoes findings from other research, which demonstrates that users and non-users alike feel there is limited available knowledge which in turn impacts decision-making around e-cigarette use (Farrimond, 2016; Rooke et al., 2016; Wilson et al., 2020, 2021). It appears that for many on both sides of the e-cigarette debate, information can sometimes be exaggerated, leading to extreme positions and confusion which can also be noticed within participant’s own talk.

The social acceptability and stigma spectrum

Participants presented nicotine dependency on a spectrum and discussed where e-cigarettes lie along this spectrum.

[FG2 Lines 256–283]

Simone (dual):

I haven’t accepted the fact that I’ve got a problem, I know that I should quit but I’m not really willing to do so, so e-cigarettes are sort of me telling myself, oh I do need to quit so I’m doing this, but I am still smoking, whereas if I just started having patches I wouldn’t be smoking, so that is like true admittance that I do need to quit

Dominic (dual):

Also, where you get them from? You have to get tablets and patches from a pharmacy or like Boots or something whereas you can go to a really cool vape shop and there’s like oh there’s loads of flavours and stuff whereas you’d have to go to the bloody pharmacy and say have you got any patches in, it just feels more horrible […]

Simone (dual):

Also, I was gonna say, if you go to the doctors and you say that you are trying to quit smoking, they will prescribe one of these methods, where I don’t think they will prescribe them for e-cigarettes

Researcher:

What do you think is the issue with ‘admitting’ you have a smoking problem?

Valentina (dual):

For me, it’s not that it’s embarrassing, it’s more that if I admitted it, it would mean that I would have to stop or I would have to be taking the measures to, because that comes with admitting there’s a problem, if you admit you have a problem, by the very definition of problem, there’s something not right so therefore you have to do something about it, so if I think oh I’ve got a problem because I’m smoking I’ve got to do something about it, it’s not the embarrassment, it’s the fact I’ll have to stop smoking

Tony (ex-smoker):

I think it’s just the enjoyment of it as well, kind of like the more positive and the pleasure of it outweighs the negatives at the moment, well not for me, but that’s kind of what I was feeling when I was dual using, was that I didn’t think it was worth it, and then over than the last few months when I have started doing more fitness and stuff like that and running more, I’ve kind of made more of a conscious decision to stop smoking

Simone (dual):

I think social pressure is a huge thing as well, if your entire friendship group is socially smoking whenever you have social events then you’re not gonna feel as pressured to stop smoking but if everyone did stop smoking you would probably stop smoking because no one around you would be

Simone [dual/FG2] discusses ‘true admittance’ and how e-cigarettes can act as some form of middle ground between quitting and continuing to smoke. Self-deception and admittance of smoking behaviour has been noted in other research exploring why young adults continue to smoke despite knowing the risks (Gough et al., 2009). She goes on to state ‘if your entire friendship group is smoking’ which implies that her decision to smoke is a product of the behaviour of others, inferring that individual factors are somewhat irrelevant. The statement attempts to convey that individual smoking behaviour in social situations is purely influenced by whether others are also partaking in that behaviour. It is possibly an attempt to shift responsibility around her decision to smoke, allowing her to avoid shame or self-stigmatisation. Some participants therefore positioned themselves where they can be perceived as ‘social smoker/non-dependant’ rather than ‘dependent’. This firstly puts them in a position of power as it implies they are more in control of their cigarette use when compared to a ‘full time’ smoker. It may also be an attempt to avoid internalisation of the social vilification that is often associated with dependency (Matthews et al., 2017).

Also note the negative repetition of ‘problem’ throughout Valentina’s [dual/FG2] statement. Her reluctance to state what the problem is by verbally covering it with the word ‘problem’ rather than explicably stating it supports the narrative about refusing to acknowledge and hide dependency. Valentina also states that if she accepts the problem, it is a ‘fact’ that she will have to stop smoking. Often, those that label themselves ‘social’ smokers rather than smokers do so as to separate themselves from the negative consequences of regular smoking and accepting their dependency (Schane et al., 2009).

The absolutes used in an alternative extract by Dominic [dual/FG2] ‘always’, ’never’, capture the language of extreme magnitudes and propose absolute conditions when it comes to either being a smoker or not being a smoker. This can negatively influence cessation efforts, as typically individuals smoke on the journey to permanent quitting (Gokbayrak et al., 2015), often fluctuating between quitting and smoking. This means that this exclusive mindset (smoker vs. non-smoker) can be problematic. For some, vaping can be experienced as substantially different from smoking, whilst also maintaining some aspects of it, suggesting that dependency and control can be experienced as co-existing (Keane et al., 2016).

Stigmatisation also exists in relation to e-cigarettes. It appears that within both discussions, there was a consensus that certain e-cigarette devices are more acceptable than others, and there is implicit distinction between the more socially acceptable ‘smaller and thinner’ [Tony, ex-smoker/FG2] e-cigarette devices that blow small clouds and are only used for stopping smoking purposes, compared to the ‘big massive things where they have smoke coming out’ (Poppy, [dual/FG1]). It was also desirable for e-cigarette use/devices to be considerate of others (‘it doesn’t have that smell to it either '[Mary, smoker/FG1]).

[FG1 Lines 314–329]

Barbara (ex-smoker):

Yeah, I find that very strange all the recreational use

Mary (smoker):

It’s very bizarre, I think like I just said if it was marketed as more of a quit smoking aid, like nobody is gonna go in and buy nicotine patches if they aren’t trying to stop smoking

Barbara (ex-smoker):

You wouldn’t go arrange to meet 100 people and smoke 20 cigarettes, would you?

Poppy (dual):

It’s weird as well because if you look at the person and the actual vape type they have, because you will usually find the girls will have the smaller one with the pretty colour and y’know the guys who will have the grunge ones with the big – and they are the ones who tend to sit in and y’know the shops where they sell the vapes and they’ve got the big massive things where they have smoke coming out, so it’s like people tend to go for like a shape and size

Barbara (ex-smoker):

It’s very stereotypical, isn’t it? like a trend thing

Poppy (dual):

Yeah, I dunno if it’s like conscious like, I want the lady type one. Mine were always pretty pink or pretty colours

Barbara (ex-smoker):

I always get the plain ones because I don’t see it as a fashion accessory at all

Poppy (dual):

No, no It’s not that I saw it as a fashion accessory, it was kind of like, it was more like ladylike, I didn’t want that big thing y’know the little one it was more ladylike, it’s like having a posh cigarette

In the extract above, the use of the intensifying word ‘very’ by Barbara [ex-smoker/FG2] emphasises the negative implications, which is then repeated by Mary, illustrating preference for agreement by repeating the extreme adverb. Mary also goes on to use the extreme case formulation ‘nobody’, implying that if e-cigarettes were clearly marketed as quitting smoking devices, then no one would use them recreationally. The stigma discourse is then heightened as Poppy protects herself when she states ‘it’s not that I saw it as a fashion device’ following the previous comments from Barbara and Mary. Using e-cigarettes as fashion accessories, part of a trend, or for any other purpose other than quitting smoking was frowned upon within both Focus Groups. With Poppy positioning herself in this way, she is using her own judgement and trying to position herself acceptably in regard to the peer norms in the group (Foucault, 1975).

These ideas expand on concepts from Bell and Keane's (2012) discussion around the ideological challenges surrounding the binary categorisation of ‘good’ and ‘bad’ nicotine. E-cigarettes were initially brought into the public health view as part of the procedure of tobacco control, moulded to fit this regime and therefore branded as a ‘remedy’ to nicotine addiction (‘good’ nicotine). E-cigarettes were seen as ‘clean’ and ‘safe’ forms of nicotine when compared to the ‘unsafe’ and ‘deviant’ nicotine seen in cigarettes. Recreational device use has blurred the boundaries between ‘good’ nicotine and ‘bad’ nicotine (Bell & Keane, 2012) and it appears that bigger devices are falsely associated with recreational use. By engaging in ‘good’ and 'respectable' e-cigarette use, participants distance themselves from anything that would not contribute to a social identity that is acceptable, positioning themselves as moral, morality is a key concern for stigmatised smokers (Gough et al., 2013). This suggests that there is a constructed social understanding that e-cigarette use should be, firstly, utilised only for stopping smoking purposes, and secondly practised with sensitivity for others. The disapproval of recreational e-cigarette use stems from concerns that e-cigarettes pose a risk to younger people and/or as a gateway to cigarette use.

In regard to e-liquid flavours, there was concern that particular flavours were also ‘targeted at the young ones’ [Barbara, ex-smoker/FG1]. The concern for young children, discussed in both discussions, positioned the speakers as considerate of others, even though their habits may damage their own health, positioning them as moral. Participant accounts demonstrated how they managed their stake, to prevent projecting themselves as immoral (Edwards & Potter, 2000) by identifying they are aware of the ‘moral’ way to use an e-cigarette.

Irrespective of the varying levels of acceptability of e-cigarette products themselves, when compared to cigarettes, they were still viewed as more ‘socially acceptable’ (Barbara, ex-smoker/FG1). There was general consistency within the accounts of the users that e-cigarette use had accentuated their nicotine dependency, which contradicts the previously discussed ‘acceptable’ way of using them (quitting smoking and eventually eradicating dependency), that had been co-constructed across both discussions.

[FG1 Lines 87–101]

Barbara (ex-smoker):

I don’t go any prolonged period of time without having it – without vaping, at the end of this forum it’s probably the longest time I’ve been without it, this is probably one of the longest times I’ve done because I vape permanently, it even puts me off going places, so, if you go to the cinema, before I go in its like vape vape vape vape vape and then as soon as you go out the door it’s like the first thing you do

Poppy (dual):

I used to go to the toilet and vape, but I was so nervous about setting the smoke alarm off that I would be over the toilet vaping and trying to blow the smoke the toilet as I’m flushing the chain

Vic (ex-smoker):

Can they set them off though?

Poppy (dual):

But I was just so nervous, nah I was exactly the same, my vape that was in my back pocket, so if I went to the toilet for a wee I would be smoking using that vape, even in this building I would do it [laughs]

Barbara [ex-smoker/FG1] specifies the amount of time she can go without using the e-cigarette. The ‘longest’ and ‘permanently’ are maximum case formulations, which propose an amount of time that is unacceptably long (Pomerantz, 1986). The negative repetition of the word ‘vape’ by Barbara [ex-smoker/FG2] places further emphasis on how extreme her e-cigarette use is. Poppy uses conceding language when she states she ‘even’ vapes in this building, where it is illegal, suggesting that nicotine dependency from e-cigarettes has resulted in her breaking laws to consume it. She laughs when she is discussing this, using humour to minimise the seriousness of her statement.

It is evident that stigmatisation has a significant impact on decision-making around dependency behaviours (Matthews et al., 2017). These data suggest that these types of behaviours are often compared dichotomously with one another, reflecting the previously discussed binary categorisation (Bell & Keane, 2012). However, this can be preventative in terms of smoking cessation. Categorising e-cigarette products as ‘bad’ or ‘good’ could potentially prevent certain people quitting (for example, if they preferred bigger devices but felt stigmatised using them, so eventually went back to smoking).

Conclusion

This analysis proposes two main discursive frameworks that participants draw from to communicate their perceptions of e-cigarettes: (1) uncertainty and risk and (2) the social acceptability and stigma spectrum. The findings demonstrate how this form of analysis can provide insight into how health-related phenomena, and in this case, e-cigarettes, are discursively co-constructed and assigned meaning as a social practice (Keane et al., 2016) through shared interaction.

Exploring vaping as a social practice has been suggested previously (Keane et al., 2016), as it can provide a more nuanced understanding of the interplay between the elements which promote the continuation and reproduction of the practice (Blue et al., 2014). This expands on previous claims which challenge the rhetoric of ‘individual choice’ (Bell et al., 2011) in health-related behaviour and public health, emphasising the importance of ‘recognising the social, cultural and political context in which public health policy is conceived and carried out’ (Bell et al., 2011, p. 5). Understanding health behaviours as social practices requires a paradigm shift – a shift in the foundation of public health policy, and corresponding forms of methodological inventiveness and ingenuity (Blue et al., 2014). Although the current paper cannot offer concrete solutions to how to achieve this paradigm shift, what it does suggest is that these social practices can be accessed, understood, and constructed using language. Forms of discourse analysis can offer a method of exploring these social practices, as they are made real through discourses, and cannot be understood without reference to discourses that give them meaning (Phillips & Hardy, 2011). Although there are a multitude of approaches to discourse, they all share the notion that what makes the social world, including our practices, in this case vaping, can partly be accessed by examining discourse (Dremel, 2014).

Alternative qualitative analyses focus on what people talk about; this approach looks at what people do with what they talk about. What people do with what they talk about is arguably unintentional, which can provide insight into the nuances of morality, status, and positioning as people discuss and interpret public health and health-related behaviours, particularly behaviours that may be more stigmatised. Micro-analysis of specific episodes of social interaction can also identify macro-level discourses, reconceptualising the false dichotomy between external social structures and individual agents, by acknowledging and highlighting their interdependence (Burr, 2015) and therefore allowing for the exploration of vaping as a social practice (Keane et al., 2016).

When considering the question ‘how can discourse analysis enable us to generate understandings of e-cigarettes that are useful for health promotion?’, this paper demonstrates that drawing on the analytic techniques of discourse analysis can shed light on vaping as a social practice by providing insight into how existing messages are interpreted and discussed in conversation between diverse social actors. This can help with communication in a field where there is a lack of certainty in expertise (Lucherini, 2021) as it contributes to refreshing the terms in which health-related behaviours are framed and evaluated.

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Additional information

Funding

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Notes

1. Popcorn lung (bronchiolitis obliterans) is an uncommon type of lung disease (not cancer). It is caused by a build-up of scar tissue in the lungs, which blocks the flow of air.