Tobacco harm reduction discourse tends to be focused primarily on the relative risk of various nicotine and tobacco products. Yet, analysis of our participants narratives emphasizes that THR is an approach that is much broader in focus and reminiscent of ongoing debates in the addiction field more generally about what exactly constitutes harm reduction.54,55 Participants shared 1) various individual strategies they employed to reduce tobacco-related harms, but also underscored 2) the complex balancing act involved in navigating the risks of tobacco use within a context of broader social and structural harms. Framed within this broader socio-structural context, participant perspectives also highlighted 3) a pragmatic, nonjudgmental orientation and 4) a person-centered approach as critical elements of THR. These findings, exemplified with quotations from participant narratives, are presented in more detail below alongside a discussion of their implications and how they relate to existing research.
Individual Strategies
"Harm reduction means just trying to make the situation the least harmful it can be, even if that means, sometimes still engaging with the harmful behavior, you can make it less harmful by doing less or taking care of yourself in other ways. ... if I'm craving nicotine, and I choose a vape over a cigarette, that is harm reduction. Or only smoking half of a cigarette instead of the whole thing. That sort of thing is harm reduction.”
- Rocky, a 22-year-old queer person who identifies as gender queer/gender questioning (P168)
As Rocky’s quote above summarizes, our participants’ narratives generally emphasized two ways in which they worked to minimize individual harms associated with combustible tobacco use: substitution and reducing frequency. First, and in alignment with public health conceptualizations of THR as the substitution of combustible tobacco use with less harmful nicotine-containing products,2,56 many participants described substituting their smoking with what they perceived to be less harmful NT products. For example, Valentina, who described her smoking both as a way to reduce stress and anxiety and as a guilty pleasure, described the process that she takes to minimize smoking-related harms.
"So, right now, I'm using the Puff Bar stick…I feel like it's a better alternative to cigarettes. …I tried to completely stop [smoking], but …it's hard…it's really hard…I just try to use the Puff stick as much as I can when I need to because I feel like it's a…cleaner alternative than cigarettes... Obviously, I do fiend for [a cigarette] here and there. So…I do run through like, a pack a month, which is, in my head, okay, because … it used to be way more than that. So, I just feel like, Okay. I'm doing a little bit better now."
-Valentina, a 22-year-old cis woman who identifies as bisexual and gay/lesbian (P553)
Similarly, Stewart, a 20-year-old, nonbinary person who identifies as bisexual/queer, emphasized their process in moving away from cigarettes to reduce harm.
“Right now, I'm exclusively using the nicotine vape. I've completely cut out cigarettes and loose-leaf tobacco, and I'm hoping that now I can start to transition either to … lessening my frequency of use or lessening the strength of the nicotine in the juice that I'm using.”(P1035)
Replacing smoking with vaping was among the most common NT product substitution reported by participants, as we see with Valentina and Stewart above. However, participants, like Valentina and Stewart, also expressed tremendous uncertainty about whether this practice was in fact harm reducing. 57 As Valentina said:
“So mentally, I'm just like, ‘Okay. I'm technically not smoking a cigarette’ [by vaping]...The not-okay part is not knowing like: ‘Okay. What damage is it really doing?’...And I'm pretty sure it's like an evil, little scheme from the tobacco industry where it's just like, ‘Okay. Yeah, let's make people feel better about smoking these Puff Bars,’ when in reality, they're probably doing the same damage, and I wouldn't know because I don't know what's in it...And I wish I would know." (P533)
Uncertainty related to the relative risk of various NT products was common in interviews, with participants describing their own individual tobacco harm reduction strategies but then lamenting about whether their efforts were actually reducing harm. Other participants, rather than experimenting upon themselves in the face of uncertainty, chose to maintain cigarette smoking instead.
"E-cigarette companies are more of a recent thing, and so, there's less transparency... People… already know that cigarettes are bad because we've always been taught that. But then these e-devices…there's a lot of gray area, like: ‘What is actually happening to you?’ And I think it's slowly being uncovered with all of these lung-collapsing cases…they're definitely both really bad for you. I would rather smoke a cigarette, because there's more research and data on those than on these e-cigarettes." (P213)
-Hannah, a 20-year-old bisexual cis woman
While the long-term safety of e-cigarettes is uncertain, concerns related to popcorn lung or “lung-collapsing cases,” as Hannah refers to, are likely due to highly publicized vaping-related hospitalizations and deaths peaking in 2019 that raised concerns regarding the safety of nicotine-containing vapes.58 Research has since found that the increased incidence in vaping-related lung injuries observed during that time “were strongly associated with vaping tetrahydrocannabinol (THC) which contained Vitamin E Acetate mostly obtained from informal sources.” 38,58 In spite of this discovery, studies suggest that misperceptions about the relative harm of nicotine vaping compared to cigarette smoking continues to increase 56 regardless of accumulating evidence suggesting that the substitution of smoking with nicotine vaping will result in tremendous benefits to population-level health.2,59–61 Data from our participants is consistent with this paradox.
In addition to NT product substitution to reduce individual harms from smoking, other participants reported reducing the frequency with which they smoked cigarettes, including breaking cigarettes in half, giving away cigarettes to reduce the amount available in their packs, setting daily or weekly “rations” for themselves about the number of cigarettes they could consume, or substituting other substances like cannabis or caffeine. Among the most prominent of strategies, however, was the use of cannabis to reduce the frequency of smoking, with one participant describing this practice as “treatment of myself by myself” (P1202, M, a 24-year-old gay cis man). For example, Zephyr Breeze explained:
“I used CBD as a way to help fight the [nicotine] cravings…it helps get rid of some of the pain that I have in my body, and it also helps fight the cravings that I have for cigarettes, so that I can limit my use down to like, four a day, and then sometimes it's three. And sometimes if I'm feeling really good, it's only two....” (P250)
-Zephyr Breeze, a 21-year-old participant who identifies as bisexual and bigender
Similarly, Jeremiah shared that:
“When I was 21 or so…I kind of dropped the box mod altogether, because I found CBD…I feel like it's not as nasty as cigarettes ... it's not as expensive either, and it's not addicting.” (P2583)
-Jeremiah, a 23-year-old cis man who identifies as bisexual
Co-use of cannabis and tobacco has received much attention in the literature but generally through focusing on the potential of cannabis to perpetuate tobacco use and/or inhibit smoking cessation.62 Conversely, our participants’ narratives emphasized cannabis—sometimes cannabidiol (i.e. CBD) alone, sometimes with THC—as an important material for tobacco harm reduction, describing the ways in which cannabis reduced their reliance on or entirely replaced their cigarette smoking.
Implementing nicotine or cannabis product substitution and reducing the frequency of smoking was commonly discussed by participants. However, as the next section will emphasize, narratives also evocatively described the broader harms that participants negotiated along with their NT use, stressing the ways in which they needed to balance the harms associated with tobacco use and the other harms they confronted in their everyday lives. Rose, a 24-year-old participant who described severe bullying and struggling with self-harming, depression, and anxiety since the 8th grade succinctly drew attention to the balancing act that many participants negotiate between individual tobacco-related harms and the broader social and structural harms that surround their everyday lives.
“Smoking cigs, I'm sure people do judge me for that. But I just think that my past with mental health issues and stuff like that, like if they knew me, they'd be like, 'You know, just glad she's not doing anything heavier.'” (P1073)
-Rose, a 24-year-old participant who identified as bisexual, nonbinary femme
Broader Harms
“There's so much going on, and there's so much emphasis in trying to do the best for yourself while failing to recognize the structure of our society that makes it so that people have to rely on these things [e.g NT] in order to function on a day-to-day basis...”(P1035)
-Stewart, a 20-year-old, nonbinary person who identifies a bisexual/queer
While participants described the practices that they used to reduce smoking-related harms, their narratives were also noteworthy in the extent to which they conceptualized tobacco harm reduction as inextricable from the broader social, economic, and health harms that negatively affect people who happen to also smoke, as Stewart and Rose allude to above. Given extensive research that documents the ways in which stigma, material disadvantage, and mental illness strongly predict smoking,63–65 it should not be surprising that interviews with people who smoke and who identify as SGM would reveal a number of broader social and structural harms that affect their everyday lives and contribute to their NT use. Analysis of our participants’ narratives overwhelming emphasized how a tobacco harm reduction approach must situate tobacco use inequities within the broader inequities in which they are created. For example, when asked towards the end of the interview what could be done to better support people who use NT, Lisa mentioned “guaranteed housing and healthcare,” explaining:
“I feel like the biggest thing would just be more indirect quality-of-life improvements. I mean, I feel like society is pretty aggressively anti-smoker at this point…I feel like most people smoke because their lives could be better... Like, guaranteed housing and healthcare. ...I feel like…the biggest correlators for smoking are poverty and stress levels. So, like, we got to get at the root of the problem...” (P4167)
-Lisa, a 20-year-old bisexual cis woman
The predominant discourse on tobacco harm reduction often neglects to situate NT use within this broader scope of harms, yet definitions of harm reduction in the drugs field have long drawn attention to the social and structural inequities implicated in drugs use in the first place.54 Nadine Ezard, writing about harm reduction in injection drugs use in 2001, argued for a focus on vulnerability reduction, meaning that attention be paid to the underlying structural conditions of drug-related harm which “constrain choices and limit agency” for some groups of people. 66 Such an approach not only decreases the stigma of and creates empathy around substance use, but it also identifies under-leveraged opportunities for intervention that target the fundamental causes of drug-related harms rather than the individual behavior of drug use.67 Many of our participants’ narratives emphasized housing and financial insecurity, social marginalization, and discrimination as fundamental causes of NT use, structural harms that so often fail to be considered a piece of the tobacco control agenda. For example, as one participant eloquently described:
“I get plenty of messaging about why tobacco is bad, why the tobacco industry is bad, why the tobacco industry specifically targets queers and poor people and other marginalized communities to continue profiting off of our deaths…That's all very clear to me. And … I don't actually think I'm getting any messaging … from the tobacco industry. The thing that makes me engage with tobacco and nicotine anyway is because I feel bad so much of the time…, and the short answer to why that's true is capitalism....my rent is more than half my paycheck, and my partners had to move away because they can't afford it here, and climate change … [and] we've been in our homes for a year because we just couldn't get it together to do things better. …if I didn't need to grasp at whatever I could to cope with what's happening around me, there would be no benefit to this for me, and I would have no desire to smoke or anything else.” (P822)
-Candy, a 25-year-old nonbinary person who identifies as queer
In explaining how NT use fits into navigating broader structural harms in their everyday lives, other participants explicitly drew on the discrimination and social marginalization that many SGM young adults face. For example, Nancy explained how anti-SGM stigma was one part of the immense, intersecting pressures in her life that influenced her decision to start smoking:
“Being an international student, Black woman in the US facing every other kind of structural racism…was also overwhelming, and having to deal with schoolwork, financial aid, working [...], I guess – all of them just summed up into a distressful…part of my life. I was almost drowning because I couldn't reach out to anyone. ... I just was looking for a way out, a way to express all this, a way to just let it all out, let it flow and get some – some sort of – I don't know – liberation. I don't know what I was looking for, but that made me start exploring my sexuality, and I found out I was bi, and it was also very awkward coming out because as an African, it is unheard of. You know, there are laws [in Nigeria] put in place to stifle people in the LGBT community. Being gay is a crime. You have to face like, 7 to 21 years in prison for being that. So, just knowing that you'll be condemned for everything, even being yourself, despite not having anyone helping you, was a huge challenge…I picked up the habit of smoking to let it out.” (P526)
-Nancy, a 20-year-old cis woman who identifies as bisexual (originally from Nigeria)
Vivienne, a 22-year-old straight-identified trans woman who elsewhere in the interview discussed dealing with housing insecurity, under-employment, financial precarity, and mental health challenges, explained more explicitly how smoking became salient in her life in light of marginalization she’s experienced:
“Before I knew I was trans...I was made out to be gay by all of my peers. I was bullied basically into being gay, and my parents always asked me if I was gay…I was just having a lot of family issues. So, I turned to the outside for, I guess, maybe validation or support…Cigarettes were definitely enticing...Like, ‘I'm young, and I'm smoking, and I look cool,’ and whatever. … But the real reason why I was smoking was because shit was really hard at home, and you know, I'd get bullied and whatever. So...I don't know if it has anything to do with my identity, but I think the domino effect…like, all the shit that I have been through, whether it be because of my trans-ness or other factors – yeah, definitely plays a part.” (P4039)
Though widespread recognition of the social determinants of health predominates public health discourse in the United States, little attention has been paid to the broader social and structural harms, such as housing insecurity, financial instability, unemployment, and stigmatization, that are arguably fundamental causes of tobacco-related inequities. 68 Broadening our conceptualization of tobacco harm reduction beyond product substitution to include not just a recognition of, but rather an explicit focus on addressing these broader harms, “shifts the focus of change”, as Rhodes (2002) has argued in a different context, “from issues of drug use specifically to wider issues of vulnerability, and in turn, human rights.” 69 Smith (2012) details how, as harm reduction in the addiction field became institutionalized into public health, the radical roots of harm reduction programs, i.e. those focused on vulnerability reduction, were “sanitized…actively drawing attention away from the role of structural factors.”67 We must learn from the narratives of these participants and advocate that THR not only becomes a part of the tobacco control and prevention agenda in the United States, but does so in a way that foregrounds inequities. This likely will involve developing alliances with other social programs in order to intervene to reduce the social and structural harms that produce tobacco-related inequities in the first place.
Pragmatic and Nonjudgmental
"I…think of harm reduction in a non-judgmental way...instead of … quitting tobacco or whatever, it's just like, reducing the harm that it causes.... Nonjudgmental as in…it's not treating people as if they're bad for using …So, to me, it's not subscribing a moral good or bad; it's purely just objectively trying to help." (P359)
-No pseudonym provided, a 24-year-old cis woman who identifies as bisexual
Many proponents of harm reduction in the addiction field argue that harm reduction’s greatest strengths lie in its philosophy of pragmatism and nonjudgment.55 This means that the use of drugs is understood to be a common feature of human experience, and judgment is not passed on people who use drugs (PWUD). 54,55,70 Surprisingly, these distinguishing features of harm reduction have not typically received widespread attention in the tobacco field, where discussions about the relative risk of NT products predominate and where some tobacco regulatory approaches explicitly seek to increase the social unacceptability of tobacco use.71,72 Nevertheless, these features of tobacco harm reduction were quite prominent in our participants’ narratives, as exemplified by the participant quoted above who defines tobacco harm reduction as an amoralistic, practical approach that is nonjudgmental and comes with a singular goal to reduce harm. As the next quote illustrates, pragmatism and nonjudgement, as guiding principles in THR, were often situated in opposition to abstinence-only approaches where an unrealistic, sobriety-focused morality was considered to be embedded within anti-tobacco messaging.
“Everything I personally was told as a kid …about sex and ... drugs were very much just abstinent, (scoffing) you know, clean and sober. …A lot of drug-and-alcohol-dependency things, they only want to speak to you if … your aim is complete sobriety. And like I said, …the anti-tobacco ads, they don't see any nuance to anything. They're just like… ‘Smoking is bad, and you're only going to be safe if you completely don't use it.’ And I think that's just a view of the world that's kind of unrealistic right now. …So, that being said, I think that being honest about really how much harm something's doing to you is important... we really need honesty about what sex and drugs, all that, does to the body, rather than just fear mongering about the worst-case scenarios.” (P230)
-Lucas, a 22-year-old cisgender man who identifies as pansexual
Lucas’ emphasis on the need for “honest” and “nuanced” messaging and other participants’ critiques of “treating people as if they’re bad for using” raise questions about the potential consequences associated with a strictly sobriety-focused morality guiding tobacco regulatory and prevention efforts. Research on trust in public institutions suggests that trust in tobacco regulatory institutions (and therefore receptivity to tobacco prevention messages) is dependent in part upon perceptions of honesty.73 Therefore, messaging that isn’t shaped by principles of pragmatism and nonjudgement, thus not providing the nuanced information that people want in a nonjudgmental way, may ultimately sow seeds of distrust and yield unintended responses.57,74
In addition to an emphasis on principles of pragmatism and nonjudgment for tobacco harm reduction programs and policies, participants’ narratives also stressed the importance of being practical and nonjudgmental towards themselves as they attempted to practice tobacco harm reduction. Like many participants, Violet Adams talked about the importance of being “gentle” with themself, balancing the harms associated with tobacco with other stressors that contribute to their everyday lives, like the COVID-19 pandemic.
“The pandemic has made it harder to be sober. So, my relationship has changed to my sobriety in the sense of like: ‘You know what? Today, I didn't get high and I didn't drink. And that's enough for me today.’ So, it's like being…even more gentle, with myself and just letting that be the bare minimum for me. Or like, ‘I didn't smoke a cigarette. So then, today was an accomplishment.’” (P304)
-Violet Adams, a 24-year-old trans person who identifies as pansexual and genderfluid nonbinary
Balance emerged again and again within the context of taking a nonjudgmental, pragmatic approach to one’s own tobacco harm reduction practices. Candy, who experiences anxiety and was having a hard time during the pandemic, argued:
“Of all of the things I could use to cope, [nicotine pouches] feels the least destructive... I feel like if I tried to set the expectation of myself that I'm just not going to use any kinds of substances … like, period, full stop, that's not a realistic expectation. And in the past, I've tried to make decisions like that. … And what happens is that it becomes all that I think about. (uneasy chuckle) And I don't do it for a while, and then I give in and go way overboard, and it's worse. So, to me, harm reduction means I want to take care of myself. …I can't make perfect choices all the time. So, I'm going to do my best to make better ones." (P822)
While many participants expressed uncertainty and concern regarding the long-term effects of their NT use, they also valued the pleasures and benefits that they associated with nicotine and tobacco use, including alleviation of anxiety and stress, a welcome distraction or excuse to go outside, a bonding activity with friends and strangers, mindful breathing, desirable aesthetics, and nicotine’s intoxicating effects. Studies of nicotine, and other drugs for that matter, often fail to sufficiently acknowledge that many people use drugs because they experience pleasure in some way. 75–78 For example, Claude describes balancing considerations of pleasure and harm within their own tobacco harm reduction practices:
“My goal is just to use [nicotine] ...in a way that's respectful to myself [and]...does as little damage and harm as possible, but gives me a positive effect, whether it's just like a temporary way to get out of a state of mind - that's what the goal of using it is. It's to get a little bit of freedom, a little bit of change from whatever place I'm at.” P (201)
-Claude, a 23-year-old queer, agender trans person
Scholars have argued that the principles of pragmatism and nonjudgment in harm reduction represent a value neutral standpoint, compared to abstinence-only approaches that are shaped by a sobriety-focused morality.54,55 However, as Helen Keane argues, “in a context where drugs are predominantly identified as bad…and drug use as pathological, a view that drug use is neither right nor wrong is not neutral, but is itself a committed and critical standpoint.”55 It is arguably a critical standpoint to endorse nonjudgment and pragmatism in tobacco harm reduction, like our participants’ narratives suggest. It is through this critical standpoint that we are most likely to be able to balance established public health heuristics with earnest consideration of the various pleasures that people experience from using nicotine and tobacco. Such a standpoint allows for the development of tobacco harm reduction approaches that are not only attentive to people’s embodied experiences but also cognizant of the importance of their “active participation…in the co-construction of meaningful practices of safety and care” as it pertains to nicotine and tobacco use. (Race 2008; pg 422) This notion leads to another important emergent theme from our participants’ narratives: tobacco harm reduction as person-centered.
Person-centered
“It's just meeting people where they're at, in whatever capacity…[Harm reduction] conjures a more whole picture of the person… – like, try and help them however that person wants to be helped. So, maybe not necessarily shutting down their cigarette use, but maybe they want to limit it or maybe they wanted to shift it or maybe it's not even related to the cigarettes and it's related to something else that they want to talk to a therapist about., Like, being able to see the whole person and not be as influenced by those … larger morality structures." (P306)
-Tina, a 24-year-old cis woman who identifies as queer
Like Tina, many of our participants’ narratives emphasized a person-centered approach to THR efforts that includes centering and respecting life experiences, experiential knowledge, and individual autonomy. Though these elements tend to be overlooked in technical definitions of THR as product substitution, they arguably have shaped harm reduction in the addiction field since its origins.67,79,80 When we “elevate the value of users’ experiential knowledge over biomedical authorities,” we see a more complete and contextualized person, as Tina emphasized, and can build harm reduction strategies from the ground up, thus honoring the mantra adopted by PWUD from disability activism: nothing about us, without us. 67,81
Especially prominent in a person-centered approach to harm reduction is the incorporation of peers in harm reduction efforts. In fact, Riley and colleagues (2012) have argued that since the beginning of intoxicant use, peers have long educated each other about how to use substances safely.82 Some of our participants’ narratives emphasized the importance of peer support, not just as an effective strategy for cessation which is commonly used in tobacco prevention and treatment efforts,83 but also as a way to ensure compassionate and empathetic support for people who use NT products.
“Peer-based harm reduction is like, the best way.... 'Cause if you have somebody who is coming at it … from a place of like, ‘Oh, I'm an expert’…it's not an equal power dynamic and it's not something that's going to make somebody feel like, ‘Oh, I'm seen. Oh, I'm being heard.’ You want to make anybody … feel comfortable... A lot of the way that I was educated about drugs and alcohol, tobacco, everything else, was just not at a peer-based educational level; it was … punitive… like, ‘Oh, I got in trouble because I was smoking a cigarette’. Or, it was like I was being told that if I dropped a tab of acid, ‘my brain was gonna look like scrambled eggs.’ Like …that's not peer-based at all. It's just fucking lies....But when you can tell somebody the truth about what you see and what your perspective is, they're a lot more likely to listen." (P201)
-Claude, a 23-year-old agender trans person who identified as queer
Similarly, Jasmine succinctly argued why peer or community-led approaches are important.
“It's…recommendations [from] people who are in a similar position to you... rather than...a message from the top....It's like having a man tell me stuff about feminism, versus like, talking to a woman about it...You know? Like, I want to hear it from people who actually know what the experience is like.” (P94)
-Jasmine, a 20-year-old nonbinary, gender nonconforming person who identifies as bisexual
When you center people who use nicotine and tobacco by prioritizing their experiential knowledge over biomedical knowledge, you also reveal features of everyday life that create barriers to practicing harm reduction strategies. In addition to the broader harms discussed in the above section, participants also described significant barriers to THR, suggesting that the ability to practice THR was a privilege. One participant emphasized how education and training in research was necessary to sufficiently access information about the relative risk of products:
“…being able to research and how to research and what is reputable and what's not…with cigarettes, I kind of was like, ‘Oh, I have this tool. Let me look at it’…going to college and just having access and knowledge to even know what cross-referencing is…a privilege on its own. … I have friends who…because of money and issues like that, they don't have access to college, or just education and stuff. They have to work from a very young age...So, I definitely think ... research and stuff like that is not accessible for everyone…” (P299)
-(No pseudonym), a 25-year-old nonbinary person who identifies as bi/queer
Other participants emphasized the prohibitive costs associated with less harmful nicotine and tobacco products:
“Like, how they have a ton of free or very cheap options for people trying to quit harder drugs, they could make stuff to quit smoking as similarly available. Because I know they have it in a lot of stores, but it's really, really expensive. Like, I've seen - They have a huge range of nicotine gum at Costco. I see it every single day, but it is like, $50 for like, a week's supply, and that is not even slightly doable for a lot of people." (P1178)
-Moss, a 21-year-old transgender man/nonbinary person who identifies as bisexual
And still others emphasized how California’s Tobacco 21 Law[1] created barriers to THR for younger smokers. For example,
“Harm reduction means that, for people that are going to use drugs, they can do so safely, and they know what their options are. I mean, say that I'm 19 again, and I just moved here. I'm already addicted to cigarettes, but now I don't have access to buy them legally. ... I'm not tobacco age. So, I can't get any quit-smoking aids, or I can't go into like, vape shops or have any other options. So, harm reduction would be, me being able to go to somewhere, even if it's a fucking gas station, where all their shit is up to code, and I know what I'm getting…when I moved here when I was 19, I couldn't get cigarettes, but I also couldn't get quit-smoking aids. So like, what the hell? So, I just went and got cigarettes anyways. (scoffing)” (P187)
- Wisteria, a 22 year-old bisexual, nonbinary/agender person
Some research has suggested that cigarettes, as opposed to other less harmful NT products, are much easier to access when underage.85 Given evidence suggesting that some SGM young adults may initiate tobacco use young,86 access to less harmful nicotine products before the age of 21 may be important. As a result, bans on lower risk NT products as well as laws that restrict the sale of all NT products to people 21 years of age or older may have unintended consequences, especially for some young SGM people who smoke.
Paradoxically, while a person-centered approach to harm reduction warrants a recognition of tobacco users as “autonomous and responsible,” this approach conflicts with widely entrenched biomedical discourses about addiction where users are described as being controlled by their substances and having lost their autonomy in the face of dependency (Anderson and Järvinen; 2007; Rhodes 2002). However, the narratives of our participants suggest that a person-centered approach is crucial for uncovering barriers to smoking reduction and cessation, creating compassion for people who smoke, and increasing responsiveness to tobacco prevention and treatment efforts.