A high proportion of pet dogs show fear-related behavioural problems, with noise fears being most prevalent. Nonetheless, few studies have objectively evaluated fear expression in this species. Using owner-provided video recordings, we coded behavioural expressions of pet dogs during a real-life firework situation at New Year’s Eve and compared them to behaviour of the same dogs on a different evening without fireworks (control condition), using Wilcoxon signed ranks tests. A backwards-directed ear position, measured at the base of the ear, was most strongly associated with the fireworks condition (effect size: Cohen’s d = 0.69). Durations of locomotion (d = 0.54) and panting (d = 0.45) were also higher during fireworks than during the control condition. Vocalisations (d = 0.40), blinking (d = 0.37), and hiding (d = 0.37) were increased during fireworks, but this was not significant after sequential Bonferroni correction. This could possibly be attributed to the high inter-individual variability in the frequency of blinking and the majority of subjects not vocalising or hiding at all. Thus, individual differences must be taken into account when aiming to assess an individual’s level of fear, as relevant measures may not be the same for all individuals. Firework exposure was not associated with an elevated rate of other so-called ‘stress signals’, lip licking and yawning. As nonhuman animals cannot report on what they are feeling, we can attempt to infer the emotion that is likely being experienced based on changes in these emotion components  and the circumstances in which these are occurring3. For instance, behaviour and expressions during exposure to potential threats can be assumed to be fear-related while those in response to denial of access to a desirable stimulus can be interpreted as frustration (c.f.5).Emotions are short-term affective states that are elicited by internal or external events and comprise changes in several components, including neuro-physiological, cognitive , motivational and expression components, as well as the subjective experience, or feeling7, but also as therapy dogs8, assistance dogs10 or working dogs with functions ranging from search and rescue11 to police work12. Nonetheless, problems due to fear-related behaviour are often reported in both pet and working dogs , and owners may even underestimate fear in their dogs when not questioned about the specific signs exhibited15.Identifying indicators of emotions in nonhuman animals is important for assessing their welfare state as well as to improve our ability to predict subsequent behavioural responses. This is particularly relevant in domestic dogs, which live more closely with us than any other species and do not only play a role as social partners16. When an environmental threat (i.e. a stressor) is perceived, the brain’s fear system is activated, initiating behavioural and physiological stress responses17. Neuroscientists have identified distinctions between ‘fear’  and ‘anxiety’ 19. However, in practice it is often not easy to distinguish between the two concepts behaviourally, especially considering that anxiety promotes fear and vice versa20. Hereafter, we shall use the term ‘fear’ to denote both fear and anxiety responses in dogs, since they have in common that they are aversive emotional states due to a (perceived) threat that are associated with intense negative emotions and physiological changes21, and sufficient criteria to distinguish between the different concepts in dogs have yet to be established (c.f.22).Fear is a key emotion that is highly adaptive by prompting animals to react adequately to threat23. Congruent with the internal state, animals may also show specific expressions; for example, a backward position of the ears has been associated with fear in a variety of mammalian species including sheep24, goats25, pigs26, horses28 and cats29. Despite the fear response being evolutionarily adaptive, fear may often be elicited in situations that do not pose real threats, as a ‘false negative’ may entail high fitness costs (risk of death) compared to a ‘false positive’ 30. Being associated with a negative affective state, fear responses to stimuli in a human-dominated environment may have detrimental effects on animals’ welfare, without serving a function in aiding survival. For example, a fear of loud noises is innate in many animals20, and noise fears are among the most common fears affecting pet dogs32. It is important to recognise these negative affective states, to address them and to use the right measures to evaluate treatment progress.In response to fear, animals may respond by freezing, hiding or fleeing, depending on the distance of the threat and the perceived likelihood of success34, others to stress more generally37). Classic studies by Beerda et al.37 in which dogs were exposed to various potentially threatening stimuli, indicated that a lowered posture  constitutes the most consistent indicator of stress (no reference to emotions was made) of both high and moderate intensity in dogs. Furthermore, Beerda et al.36 suggested that oral behaviours (such as frequency of tongue protrusions and snout licking), yawning, body shaking and crouching are indicative of acute stress in dogs. However, as the severity (as judged by the authors) of stressors was confounded with the type of stressor 36, no clear conclusions could be drawn whether different observed behaviours were associated with the severity of the stressor or with the social vs non-social context.Surprisingly, there is a relative lack of studies objectively evaluating the expression of emotions in dogs. A few controlled studies have measured behaviour and expression in dogs when exposed to putatively fear-inducing stimuli  and a non-social stimulus (sudden appearance of a garbage bag) appears to be associated with avoidance and/or a reduced body posture, whereas effects on more subtle behaviours  were more inconsistent34. Another controlled study on puppies aged under six months inferred potential fear indicators based on their association with avoidance of different non-social stimuli considered to induce mild to moderate fear33. On this basis, a lowered posture, a lowered tail, freezing, retreating, flinching, paw lifting and barking were identified as the most reliable fear indicators, while there was no association of avoidance with ear position, tail-wagging and lip licking33.More recently, Stellato38, only few studies have been aimed to objectively quantify fear-related behaviours in dogs during noise events, and all of these used audio recordings. Dreschel and Granger39 described excessive salivation, vocalisations, hiding, pacing, panting, remaining near the owner, and trembling in dogs exposed to a thunderstorm recording at the clinic, though they did not assess to which extent these behaviours differed from a baseline condition.Although noise fears represent the most common fears in dogs40 found that dogs both classified as ‘sound sensitive’ and as ‘not sound sensitive’ (categorisations based on owners’ description of the severity of signs) reacted to recordings of a firework by increasing alertness and attention, panting, searching for the sound, startling, trembling, hiding and running away, with ‘sound sensitive’ dogs showing a greater intensity of reaction for alertness and attention, searching the sound, trembling, hiding and running away, as well as showing less resting and winking/sleeping. No significant effects were reported for variables related to the posture and tail, lip licking, yawning, vocalisations, elimination, and destruction40.De Souza et al.42 or an increase in activity45 in response to audio recordings of thunderstorms or fireworks. These different findings could potentially be explained by different coping strategies of dogs when exposed to fear-inducing noises, an active and a passive response: Landsberg et al.45 used separate scores for active  and passive  responses to audio stimulation. Both active and passive scores were increased in beagle dogs during noise exposure compared to before and after stimulation, indicating validity of the scores. However, individual behavioural parameters were not analysed45.Some experimental studies yielded conflicting behavioural results, reporting either a reduction in activity47. Recordings cannot fully represent the characteristics of real noises and the range of stimuli (e.g. atmospheric changes associated with thunder or lights accompanying fireworks) (c.f.49), and some dogs do not respond to these simulations even under optimal conditions49.While the standardisation of noise exposure in studies using laboratory settings has many advantages, it is not clear to what extent the findings can be transferred to dogs’ fear responses in a home setting. For example, with regard to noise fears, some discrepancies between owner-reported improvements in fearfulness and dogs’ behaviour when exposed to a noise recording in a clinic setting have been reportedHere we aimed to identify fear indicators in pet dogs in a real-life situation, during New Year’s eve fireworks, by comparing dogs’ behavioural expression during firework exposure to a control night with no fireworks present. By taking advantage of situations in which dogs are exposed unavoidably to these stimuli, i.e. at New Year’s Eve, it was possible to study dogs’ fear reactions without ethical concerns due to an artificial induction of fears. Hereafter we refer to dogs’ expressions during fireworks as ‘fear’ expressions, being aware that we can only infer the underlying affective state.36), a lowered tail position (c.f.45), a more backwards-directed ear position (c.f.50), an increased frequency of vocalisations (c.f.39), an increased duration of panting (c.f.51), an increased frequency of blinking (c.f.52), an increased frequency of lip licking and yawning (c.f.37), a change in activity  and an increased time hiding (c.f.40).Based on the literature, we predicted that dogs show the following behavioural expressions during fireworks compared to the control condition: a lowered posture (c.f.32). Only dogs with scores of 2 and above were considered in the current study  during fireworks on New Year’s Eve (firework video) and (2) again several days later at a similar time in the evening (control video), when they considered their dog’s behaviour to have normalised. Videos of 36 dogs were coded based on an ethogram , with fireworks being associated with more backwards-directed ears  and three (‘tail position’) out of the 36 subjects, respectively.48), the scientific data to validate this expression as an indicator of fear is surprisingly thin. In studies by Beerda et al.37, a ‘posture score’ comprising ear position along with tail position and breed specific posture was one of the best indicators of both “moderate and severe stress”37; however, even if the individual components of this score, body position, tail position and ear position often co-vary, it is important to have more detailed measures available and to take into account evidence from individual variables.In the current study, a backwards directed ear position was the indicator most strongly associated with the firework condition, and presumably a fearful state in dogs, perhaps because tail position and body posture could not be evaluated. Although “ears back” or “flattened ears” are often used to assess fearfulness in dogs  and whether they had their ears back. This could simply be explained by the low video quality, as suggested by Flint et al.33, but another possible explanation could be the confounding effects of alertness. In the firework videos in the current study, dogs often appeared to be vigilant and may thus have been holding the ears up. However, when looking at the base of the ears (as per our definition), it was discernible that the ears were turned backwards relative to the position judged to be neutral by the raters.Flint et al.53), a system for objectively analysing facial movements in dogs, a differentiation is made between several ear position changes including the ears flattener, the ears rotator and ears downwards. While the ears flattener and the ears rotator can only be distinguished in dog with upright ears but not those with floppy ears43, it is a possibility that it is the backwards rotation of the ears that is most consistently associated with non-social fear at least in dogs with erect ears. Nonetheless, while fear of fireworks appears to be reliably associated with backwards-directed ears (as measured at the base of the ears), this is only one of several contexts where this expression may be observed; for example, backwards-directed ears are also shown during frustration5, as well as in affiliative greeting situations during active submission54. Future studies could investigate subtle differences in ear position and associated contexts in more detail.Our data thus suggest that a backwards-directed ear position, judged at the base of the ears, is a valid indicator of a fearful state in dogs. In the Dog Facial Action Coding System  in some dogs in the current study. Thus it might reflect fear or anticipatory anxiety awaiting the next bang. Previous studies indicated that some dogs react to loud noise by decreasing activity, others with an increase in activity45. Besides the possible difference in active vs passive coping styles45, the diverging results of previous studies regarding changes in activity when dogs were exposed to noise recordings could possibly be explained by the novelty of the environment: In a novel environment (such as during open field tests43), exploration would be expected in the beginning of the test. Consequentially, startling stimuli could be expected to inhibit exploration, and thus activity. On the other hand, after animals have habituated to the surroundings or if they are familiar with the environment such as in the present study, they might be more likely to spend the time resting, and so an increase in activity, as in the current study, might be noted as a result of fear-inducing events.Locomotion was significantly elevated during fireworks compared to the control night. While this finding per se does not necessarily signify fear, as dogs might have adapted their own activity to the heightened activity in the household at a time of day where they were usually sleeping, pacing has previously been described as a behavioural expression of noise fears in dogs22.Panting was significantly associated with the fireworks condition in the current study, with eight of the nine dogs who panted doing so only during the fireworks. We consider panting in this situation to be fear-related, as the increased locomotion observed at the group level during fireworks cannot account for the high amount of time panting in the eight dogs that panted: four of these dogs remained stationary throughout the video, and only two were moving for more than ten percent of the time. Similarly, in a previous study, panting and pacing constituted differing coping strategies employed by different dogs55, panting is commonly regarded as an indicator of short-term stress, fear or anxiety in dogs57. One possible explanation for the mechanism underlying this association might be the need to dissipate heat, since stress leads to an increase in core body temperature, as commonly reported in dogs58 and other mammalian species (reviewed in59). Panting has been described as a consequence of the rapid activation of the autonomic nervous system, along with piloerection and trembling60 and may be a response associated with physiological arousal due to perceived external stimuli in dogs56. As in the current study, only a subset of dogs have been observed to pant during stressful situations, one contributing factor being dog size. Pastore et al.56 found a higher incidence of panting in female and larger dogs during a high-arousal situation, the latter being consistent with panting as a thermoregulatory response due to stress-induced hyperthermia, given that smaller dogs will dissipate relatively more heat from their bodies than bigger dogs due to their larger surface/volume ratio (c.f.61).While the primary function of panting lies in thermoregulation51, panting in young dogs < 6 months was reduced during exposure to fear-inducing stimuli relative to control trials33, and dogs that were separated from their owner showed an increased frequency of panting upon reunion with their owner62. Panting might thus be indicative of both positive and negative arousal (c.f. 56). These behavioural signs thus need to be interpreted in the context in which they are occurring and in conjunction with other indicators.However, some contradictory results regarding panting in dogs in relation to stressful situations have been found. Although panting is often increased in fear-inducing situations63). Thus, while panting and vocalising in a putatively fear-inducing situations may signify fear (e.g.52), they can also be shown for various other reasons. Conversely, we cannot draw the conclusion that there is no fear in the absence of these signs. For example, Overall et al.22 reported that dogs of different breeds may respond differently to loud noises . Also individuals within a single breed may adopt different coping strategies associated with either active or passive (and more subtle) coping behaviours44.The frequency of vocalisations was higher during the fireworks than during the control night , but as with panting, this effect was driven by just nine individuals – the majority of subjects did not vocalise at all during either condition. Like panting, vocalisations can occur in contexts unrelated to fear, such as during greeting, play initiation, submission, defence, threatening behaviour, contact seeking, pain, or loneliness (reviewed in3).Taken together, both the sensitivity and the specificity of vocalisations and of panting as fear indicators are low; i.e. not all fearful dogs vocalise or pant, and not all dogs that vocalise or pant are fearful. It is important to take such individual behavioural differences into account when making an assessment of an individual’s level of fear. Therefore, since relevant measures may not be the same for all individuals, it is likely that the assessment of the animal’s putative emotional state can be improved by considering evidence from several different indicators as well as the context . In view of large inter-individual baseline differences in this measure and the need to correct for multiple testing, our study may have been underpowered for detecting a significant effect – the effect size was moderate at Cohen’s d = 0.38. Blinking constitutes a component of the startle reflex64, which could potentially explain the higher rate of blinking during fireworks. However, it has also been considered as an indicator of stress and/or anxiety per se in humans (e.g.68). Moreover, in dogs, Bremhorst et al.5 found an increase in blinking frequency when dogs were frustrated. This might indicate that an elevated blinking rate may constitute a sign of stress in dogs, rather than being specific to the emotions of either fear or frustration. Perhaps one difficulty of using this indicator in an applied setting lies in the fact that blinking is also a normal mammalian behaviour necessary to prevent dry eyes69, and so it would be necessary to identify deviations from baseline rates in order to draw conclusions about possible underlying affective states. Notably, the inter-individual variation in blinking rate also during the control condition was very high in our study .In line with the suggestion by Mills40. A convenience sample was used in the current study. While the dogs in the current study were rated as mostly fearful by their owners . Other studies similarly reported hiding in dogs that were exposed to loud noises, but as in our study there appeared to be much variation in whether dogs adopted this coping strategyners see , in a st40 did not find an increase in lip licking and yawning in dogs exposed to recordings of a thunderstorm. Also, less severe fear-inducing non-social stimuli were unrelated to rates of lip licking34 or yawning33. In Stellato et al.34, subtle behaviours, including lip licking and yawning, were not affected by a non-social stimulus, but moderate correlations were found with the level of avoidance shown by dogs upon appearance of a masked stranger and when approaching the stranger. However, evidence was not conclusive, as there was much individual variation in these behavioural signs, the frequency per individual was low, and not all dogs rated as fearful based on gross behavioural measures showed these subtle behaviours at all34. Our results affirm the conclusion by Stellato et al.34 that these expressions do not represent good measures of fear in dogs, at least not with regard to non-social stimuli. Alternatively, they might play a role in social communication. Lip licking and yawning have been considered to function as appeasement signals both inter54- and intraspecifically70, and lip licking appears to be shown in situations of mild social threat (but less so during severe threats)54, as well as in greeting situations72.Our data show that even very strong fear-inducing non-social stimuli, fireworks, are not associated with an elevation in the rate of the so-called ‘stress signals’ lip licking or yawning in dogs. Similarly, de Souza et al.73) and strengthening the assumption that the measured behaviours are indeed fear-related.To our knowledge, this is the first study objectively measuring behavioural expression of pet dogs in their home settings during exposure to real-life fireworks, an approach which has advantages and drawbacks. Thus, due to using a citizen science approach, it was not possible to achieve complete standardisation and control, such as regarding firework intensity, owner behaviour and possible variation besides fireworks between the firework and the control situation. We made the decision not to restrict owners’ behaviour for ethical reasons to avoid imposing additional fear on dogs that might normally gain comfort from their owners, but also in view of having a real-life scenario, the latter being an advantage of the current study. Despite the fact that the study was not perfectly controlled, we are confident that the fireworks were the most salient arousing stimulus during the firework videos, as we discerned no presence of guests or unusual behaviours by the participating owners. Importantly, the observed behavioural differences shown during fireworks as compared to the control night are consistent with behavioural signs reported previously for noise fears in dogs, providing external validation to scales to assess noise fears in dogs where these behavioural signs are included , action tendency (e.g. escape attempts), and a variety of different expressive behaviours, may constitute the best method to infer the likely underlying emotion experienced by nonhuman animals.Nonetheless it has to be acknowledged that identifying behavioural indicators of emotions in dog is challenging, as on the one hand, domestic dogs have a very rich behavioural repertoire, on the other hand, similar expressions may be shown in different contexts, and different individuals may react differently to fear-inducing situations, as indicated in this and previous studies. Based on the component process model of emotions, inferences about the probable emotion experienced by nonhuman animals can be made based on the combined analysis of the appraisal component , the arousal component (e.g. heart rate), action tendency, and finally behavioural expressionA citizen science study was performed. Volunteer dog owners were recruited via social media, a cynological association and dog sports groups. The owners were asked to film their dog for five minutes (1) during fireworks on New Year’s Eve (firework video) and (2) again several days later at a similar time in the evening (control video) of what they considered their dog’s normal behaviour. The time gap between the two video recordings could not be entirely standardised due to the citizen science approach, but the majority of participants sent in the second video within one week of New Year’s eve, and two participants within one month. The participating owners were sent an instruction sheet, detailing that both videos should be taken indoors and under good light condition, with the camera approximately one meter apart from the dog to avoid causing any stress by filming at a too close proximity. Owners were instructed to film one dog at a time and that they should aim to have the full body in view.32. We excluded dogs from the study if the owners reported no welfare impairment at all during fireworks (Impaired Welfare Score of 1) to ensure the highest likelihood that the included dogs analysed were indeed fearful, considering that a previous study demonstrated high correlations between caregivers’ perceptions of their dogs’ sound sensitivity and behavioural indices derived from video coding of behaviour during exposure to a noise recording40.Prior to participation, owners were asked to fill in a questionnaire about their dogs’ behaviour during fireworks and to rate the ‘Welfare Impaired score’, deduced from the following statement “Please rate your level of agreement with the following statement: The overall welfare of my dog is strongly compromised by fireworks”, which could be answered on a five-point Likert scale from “disagree strongly” (1) to “agree strongly” (5), c.f.31, only dogs receiving anxiolytic medication and dogs with known loss of hearing were excluded from the study.For ethical reasons, no dog was exposed to additional stress. Thus, the owners were advised to carry out all measures they would normally take in an effort to alleviate their dogs’ stress, and to behave as they normally would during fireworks. This could include petting or feeding their dogs as well as using pheromones, homeopathic or herbal remedies, supplements, Bach flowers or aromatherapy. Since a previous study indicated that solely psychoactive medication, but none of the alternative products, led to a considerable improvement in firework fearsThe subjects were of various ages, breeds, sizes and both sexes, including 17 mixed breed dogs and 19 pure breed dogs of 15 different breeds (Supplementary Table Two dogs were eating/licking a kong for the majority of time during the fireworks video (one of which did the same during the control video). Four dogs showed eating for a few seconds only. Fourteen dogs were petted during part of the time during the firework videos (six of which for more than one minute), while during the control videos five dogs were petted (one for more than one minute). Although we did not specifically ask about the identity of the people present during the videos, no more than two people (including the filmer) could be discerned in any of the submitted videos.The study was assessed and approved by the cantonal authority for animal experimentation, the Veterinary Office of the Canton of Bern (Switzerland) (Licence number BE28/17) and complies with the «Guidelines for the Treatment of Animals in Behavioral Research and Teaching» of the Association for the Study of Animal Behavior (ASAB). All participating owners gave their informed consent to the use of their videos for scientific analysis.www.solomoncoder.com). The coder was blinded as to whether the videos were recorded during fireworks or control nights; however, in some of the videos it could be guessed which situation was filmed based on the context (e.g. presence of champagne glasses).As not all the submitted videos were of the requested duration of five minutes, but most videos were at least 3 min long, it was decided to code the first three minutes of each video. Some videos  were shorter. Thus, the mean duration ± SEM coded of the firework videos was 172.38 ± 4.19 s, and the mean duration ± SEM of the control videos was 147.86 ± 8.03 s. Videos were coded using Solomon Coder  were coded . Because some rarer behaviours were not shown at all in the randomly selected videos , reliability coding for these variables was subsequently repeated based on a non-random selection of 13 videos, which included all videos in which either panting or hiding occurred at all according to the first coder’s codings. Cronbach’s alpha was calculated to assess reliability of the frequency of events per minute, the proportion of time spent in different behavioural states and the means of the posture, ear and tail scores . Reliability was good at α = 0.70 or higher for all variables included in the analysis  and IBM SPSS Statistics Version 23 .S = 0.75, p < 0.0001) and the control condition ; therefore, we created a composite variable labelled ‘lip licks’ (defined as the sum of ‘snout licks’ and ‘lip smacks’) to be used in further analyses. One dog was sleeping throughout the control condition, and therefore no frequencies of oral behaviours were coded for this dog during this condition. Thus, the following variables were compared between the fireworks and the control condition: ear position, frequency of blinking/min, lip licks/min, yawns/min, vocalisations/min, proportion of time panting, proportion of time moving and proportion of time hiding.The variables ‘body posture’ and ‘tail position’ could not be included in the analysis, as dogs were mostly in a lying position during the control condition, so data from both conditions were available for only five (‘body posture) and three (‘tail position’) out of the 36 subjects, respectively. As vocalisations were rare , frequencies of barking, whining and howling were added up to yield a single ‘vocalisation’ variable Table . The fre74 was calculated as d = Z/√N (c.f.75).As most variables did not fulfil the requirements of parametric analysis, Wilcoxon signed rank tests were used to compare behaviours and scores between firework and control videos. As a measure of effect size, Cohen’s dTo be able to gauge the significance of the results in view of the multiple statistical comparisons, we include the corrected alpha level according to sequential Bonferroni correction in Supplementary Table Supplementary file1


Many global health organisations have adopted formal strategies to integrate gender in their programming. In practice, few prioritise the issue. Institutions with considerable global power therefore largely overlook fundamental drivers of adverse health outcomes: gender inequality and harmful gender norms. We analyse the factors shaping attention to gender in organisations involved in global health governance.Drawing on scholarship from the fields of organisational behavior and management, sociology, international relations and the policy process, we undertook a thematic analysis of peer-reviewed scholarship and organisational documents. We also conducted 20 semi-structured interviews over Skype with individuals working at the cross-section of gender and health.In seeking to reform the policies and practices of global health organisations, gender proponents confront patriarchal organisational cultures, hostile political environments and an issue that is difficult to address as it requires upsetting existing power structures. Proponents also face three linked challenges internal to their own networks. First, there is little cohesion among champions themselves, as they are fragmented into multiple networks. Second, proponents differ on the nature of the problem and solutions, including whether reducing gender inequality or addressing harmful gender norms is the primary goal, the role of men in gender initiatives, which health issues to prioritise, and even the value of proponent cohesion. Third, there are disagreements among proponents on how to convey the problem. Some advance an instrumental case, while others believe that it should be portrayed as a human rights issue and using any other argument undermines that fundamental justification.Prospects for building more gender-responsive global health organisations will depend in part on the ability of proponents to address these disagreements and develop strategies for negotiating difficult organisational cultures and political environments. Many organisations involved in global health governance have adopted formal gender strategies that seek to mainstream gender in activities and programs, address inequalities, ensure gender-responsive health delivery, and strengthen responses for women, men, girls, boys and non-binary people. In practice, however, few prioritise the issue -5. InstiThe evidence on neglect is extensive. Funding for the issue, while growing, is insufficient . Men farWe analyse the factors shaping attention to gender in organisations involved in global health governance . These include multi-and bi-lateral organizations, international non-governmental organizations, large philanthropic and other funding agencies. Gender refers to the “culturally defined roles, responsibilities, attributes, and entitlements associated with being (or being seen as) a woman or man in a given setting, along with the power relations between and among women and men”. Beyond Drawing on scholarship from the fields of organisational behavior and management, sociology, international relations and the policy process, we identified four categories of factors as a useful way to examine attention to gender. These are: (1) organisational culture – the set of shared assumptions and values, as reflected, for example in an organisation’s rules, accountability mechanisms, and incentive structures, that define appropriate behavior for individuals in organisations; (2) political contexts – the environments in which these organisations operate; (3) issue characteristics – features of the problem; and (4) proponent power – the strength of concerned individuals.Factors connected to organisational culture help explain why organisations prioritise some issues and neglect others. Organisational imprinting theory suggests that the context at the time of an institution’s founding “imprints” an enduring culture, with lasting effects on priorities, strategies and operating practices . Other fThe political contexts in which institutions operate also influence organisational priorities. States create international organisations such as the World Bank, and expect them to act in accordance with their national interests . The preSociologists and political scientists point to another external political force that may shape organisational agendas: the spread of ideas and norms – standards of appropriate behaviour for actors with a given identity  – througIssue characteristics also shape organisational priorities. Organisations are more likely to prioritize issues that are soluble and have simple chains of causation. Also, they are also more likely to provide attention to issues that are perceived to cause extensive harm, that are politically uncontroversial, and that affect a sympathetic population group -24.An additional consideration is the capacity of proponents concerned with the issue to pursue collective action -28. NetwOur analysis is based on a triangulation of peer-reviewed research, organisation reports, and grey literature, as well as semi-structured interviews with individuals in global health organisations working at the cross-section of health and gender, and with critics and observers of their efforts . We searched Google Scholar, ProQuest, JSTOR databases and global health organisational websites. The search was restricted to literature in English, between the years 1980 and 2019. The search terms used were: “gender”, “gender equality”, “gender justice”, “gender norms”, “women empowerment”, “women/woman” and/or “men/man”, in combination with “global health”, “health”, “strategy”, and/or “policy”. We also included the names of major global health organisations in our search, including international organisations, UN agencies, philanthropies, government institutions, and non-governmental organisations that contribute significant funds or are involved in large-scale implementation of programs in the area of health.We undertook a thematic analysis of the collected information, using an iterative process in developing the codes . We origIn seeking to reform the policies and practices of global health organisations, advocates concerned with gender and health face several external barriers. These pertain to organisational culture, political environments and issue characteristics. They also face challenges internal to their own networks, pertaining to cohesion, problem definition and positioning. We refer to these advocates broadly as “gender proponents” rather than “gender equality proponents” or any other more specific name. We do so because, while gender equality is a focal concern for many actors, it does not encompass the entirety of the gender agenda .Patriarchal and sexist organisational cultures hinder the efforts of gender proponents. Practices, including bias favouring males, are often long-standing, entrenched and taken for granted ,40.Few gender specialists hold positions of power in these organisations (Interview (I)1, I6, I7, I8, I14, I17), and many of their colleagues see little value in applying a gender lens . Gender specialists describe feeling intimidated and marginalized :(I14).“We are not part of the boys’ club….You are yelled at and talked to disrespectfully in ways I don’t think some would do with male peers” I17).“Those genuinely working on gender equality are pushed in a corner...the geeks who drill a hole in your head wanting to have the document with a gender lens” ((I8).“I had one very senior person – a woman – say, ‘There are no gender issues in my life. I don’t know why you’re still talking about gender equality. All of that has been resolved’” Gender specialists also describe feeling overextended  . Some ofLeadership and career prospects for gender specialists  and other women are poor, despite some improvement over time ,7. Altho(I1).“If you’re a woman who says you’re a feminist, it can actually go against you because it suggests that you’re only interested in women’s issues….It’s one thing for a man to say he’s a feminist and another for a woman” Disciplinary norms pose an additional barrier to prioritizing gender . With some exception, few of the physicians, public health professionals and economists who comprise the majority of the leaders and managers in these organisations have been socialized to value gender analysis. Many emphasize technical solutions and quick fixes rather than consideration of the root causes of inequality and ill health that gender analysis emphasizes . Much me(I5).“People are bleeding; we need to be able to close those wounds. People are dying; we need to be able to fix this problem. People are starving; we need to be able to get food to those people. [All this] without recognizing those underlying factors that are creating poor health outcomes to begin with” In addition to organisational cultures, features of the global political environments that surround these organisations have hindered their prioritization of gender. While some governments champion the issue, conservative governments resist the agenda – many viewing gender equality to be a Western imposition and/or a threat to their cultures – prompting global health organisations to act cautiously for fear of offending key constituents  . For insAn additional impediment are historical initiatives that have led to a conflation of gender with a concern for women (I19) . In the Also, the MDGs reinforced a narrow understanding of gender by largely ignoring complex power relations, promoting a limited set of indicators that encouraged a “quantified numbers game” (I1), and pursuing a categorical approach that targeted women separately from men  . Among tMany gender proponents see this conflation of gender and concern for women as undercutting the application of what they call a true gender lens, and bolstering instead the examination of sex differences from a biological perspective . Respondents express their frustrations:I3).“I think a lot of institutions have gender as code for ‘women’” ((I19).“People feel that if they are doing women’s health, they are doing work on gender” Moreover, global health organisations often limit their consideration of gender to reproductive and sexual health, violence and infectious diseases , to the neglect of non-communicable diseases, epidemics, injuries and other conditions shaped heavily by gender norms and power relations I1, I8, I11) , I8, I11,54. TherThe nature of the issue itself also hinders prioritization of gender considerations in global health organisation programs and practices. Critics claim ‘gender’ is ambiguous, complex, and academic  . One res(I3).“The word gender is off-putting and different people interpret it to mean different things. As a term it is also hard to operationalize in practice” Another respondent notes an implication of this alleged opacity, contrasting the issue with more easily grasped problems such as violence against women (I19): “It’s really hard to grow a movement around gender.” A related difficulty is gender’s cross-sectoral nature. Like nutrition, health systems strengthening and environmental sustainability, addressing gender requires engagement with multiple technical areas. Gender is the responsibility of many actors, making it susceptible to being the responsibility of no one .Most challenging, unlike many global health problems such as vaccine delivery, addressing gender inequalities requires fundamentally upsetting existing power structures . As respondents note:(I7).“We’re talking about changing the sexual division of labor. We’re talking about changing gender power relations. We’re talking about very threatening ideas. And there are consequences for people” (I5).“These are deeply entrenched ways of being…people are hesitant to step into that complex muddy grey space and work to see the transformational change that is needed” Often, the politically powerful individuals able to influence the deep structures that keep gender inequality in place have little incentive to do so, while the populations most adversely affected are politically marginalized (I12). Recognizing this challenge, many global health organisations adopt technocratic or integrationist approaches to gender – adding it on to organisational activities – rather than a transformative approach that aims fundamentally to alter institutional practices and norms (I5) ,41.While many impediments to addressing gender stand external to proponents, some concern the proponents themselves. These linked internal challenges pertain to cohesion, problem definition and positioning.Tight communities work actively to address some concerns in global health, including tobacco control, tuberculosis and newborn survival -58. By cOf the three networks mentioned above, the one most centrally concerned with gender broadly understood is a group of individuals working under the guise of gender and health. Many are academics who gather at forums on women’s health (I8). Most gender specialists within global health organisations are also part of this network. These individuals are concerned with the ways in which societies assign roles, responsibilities and expectations to men and women, and the influence of these social constructions and of gender relations on health outcomes. Many identify with a larger concern surrounding gender and development, whose roots lie in part with the women’s movement . The focus of these individuals is broader than the health of either sex or a particular issue such as HIV/AIDS.A second network, emerging in the late 1990s, is comprised of individuals concerned with masculinities and health. The masculinities and health movement is two-pronged in nature. One group has sought to raise the profile of men’s and boys’ contributions to women’s health, advancing the critical role that men and boys have in transforming harmful gender norms and unequal power dynamics . The othThe largest of the three networks is comprised of academics, advocates and practitioners addressing the health and well-being of women and girls. Some individuals are concerned with this area broadly, but most focus on one or more specific issues, including maternal health, sexual and reproductive health, violence against women, and HIV/AIDS. Most claim a concern with gender, but unlike many members of the other two networks, few identify gender equality as their central focus. Several forums have brought these women’s health proponents together . These include the 1994 International Conference on Population and Development (ICPD) in Cairo, the 1995 Fourth World Conference on Women in Beijing, the Association for Women's Rights in Development (AWID) international forums, and more recently, a series of Women Deliver conferences and a 2012 Commission on Women and Health ,66.Differences among gender proponents concerning the nature of the problem and solutions contribute to this lack of cohesion . One gender proponent describes the situation:(I9).“You might imagine that they could be unified under an all-encompassing theory of gender but that’s not what really happens” One point of disagreement is whether reducing gender inequality or addressing restrictive gender norms should be the primary goal . Proponents advancing the former – individuals predominately involved in women’s movements – see the need to complete the unfinished agenda of achieving gender equality. Proponents supporting the latter – newer to the field of gender and health – argue that restrictive gender norms adversely affect both women and men, and see a need to focus on gender to improve well-being for all populations. Still others don’t see addressing gender inequality or restrictive gender norms as “mutually exclusive”, since “gender norms underpin gender inequality”, which “can work against men although historically it is women who have been disadvantaged” (I3).A related concern are the subjects of male health and masculinities, and the role of men in gender initiatives. A number of proponents are uneasy about those advancing a concern for masculinities in global health and development, worried that they may ‘male-hijack’ the gender agenda, encroach on limited funds, and undermine work focused on women . ProponeSome proponents argue that the very concept of “gender norms” is ambiguous, that norms are only one determinant of health outcomes, and that an excessive focus on these will lead policy-makers to believe that there are simple solutions to gender problems in health  . As one (I6).“Norms are, at most, one among a number of determinants of action… My guess is that the policy language of norms has mainly come from global North contexts. In global South contexts, issues like violence, poverty and power, rather than norms, leap to the eye when thinking about health issues such as AIDS, malnutrition, refugees, poor housing and sanitation, and pollution” Yet another tension is over which health issues to emphasize (I4). Gender proponents historically have focused on violence against women and issues connected to reproduction, including sexual and reproductive health and rights, women’s vulnerability to HIV infection and maternal survival. Some proponents are critical of this extensive focus on reproductive issues, arguing that it crowds out attention to other pressing concerns such as non-communicable diseases (I8). A related tension is the extent to which to engage politically controversial subjects such as abortion access and LGBTQ rights. While most gender proponents agree that these concerns are critical for achieving gender equality, for tactical reasons some argue setting these aside temporarily to ensure progress on other aspects of the agenda. Others contend that it is a disservice to the end goal of gender equality when certain issues are separated out and “thrown under the bus” (I13).Proponents even diverge on the value of cohesion. Some see disagreements among gender proponents as a problem . One res(I7).“I don’t think there’s necessarily a relationship between cohesion and influencing others. I think that the beauty of feminist movements is that they are spaces of freedom and respect for multiple identities and ideas and framings…” In addition to concerns about problem definition, gender proponents also differ on positioning – how they should convey the issue to policy-makers and other external audiences whose resources and support are needed to advance the gender and health agenda. These differences affect network cohesion and agenda prospects.Most proponents are motivated by the goals of advancing human rights, dignity and capabilities. They differ on whether to use instrumentalist framings to achieve these ends. Some respondents argue that economic and other arguments are essential since many policy-makers are unresponsive to rights claims  . As one (I17).“For decades, the reproductive health community – I’m one of them – went around using this moral argument: ‘How could they [women] die when they are giving life to somebody else?’ We got nowhere. Do you know what got us somewhere? The economics of it. When we started costing – what does it mean for a woman to die in childbirth?” Other proponents are uneasy about the use of instrumentalist framings that do not align with their core beliefs . Moreover, they are concerned that an instrumentalist treatment of gender in global health organisations will not likely lead to transformative outcomes (I7). One respondent comments:(I7).“[During] my entire feminist organizing life people keep saying what’s the business case? It is the most irritating response…We don’t have to make a business case. There is no business case for going to church. You do it. You do it because you believe in it, because you signed up” An additional tension concerns the use of a ‘women’s empowerment’ framing . Some proponents are uneasy about its use. They worry that such a framing undermines a concern for gender equality broadly and reinforces a propensity for global health organisations to equate gender to women and to fixate on sex differences. Others, however, argue for use of this framing because it is easier to understand than ‘gender’, believe it to be effective, and contend that a focus on women will achieve similar outcomes (I4).These positioning debates shape how proponents view the work of gender specialists inside global health organisations. Some argue that the promotion by gender specialists of business and other instrumentalist arguments renders them “complicit in neo-liberal restructuring” . Others (I6).“My impression is that UN, INGO and government discussions of gender issues have been significantly shaped by femocrats’ and activists’ judgments of what they can get male ministers, parliamentarians, ambassadors and senior bureaucrats to understand about gender – and that is, frankly, very little. Categorical statistics of inequality are therefore prominent. I do this myself; if I want to catch a reader’s attention, I point out that 96% of the CEOs of the top 500 transnational corporations are men” Few global health organisations consider gender systematically in their policy-making and programming. They are impeded by their organisational cultures, political environments and characteristics of the issue. Among the barriers are entrenched, patriarchal practices; lack of training of professionals in these organisations to value gender analysis; conservative governments that view gender equality as a Western imposition; fear by government and global health officials that addressing gender will upset existing power relations; a conflation of gender with a concern for women and girls; and the complexity of the concept. Other barriers concern the proponents themselves: the absence of a cohesive community; differences among them on the nature of the problem and solutions, including which health issues to prioritize; and divergence on how to position the issue, particularly surrounding the use of instrumentalist, economics-oriented arguments.Despite these challenges, there are reasons for optimism. A growing number of global health organisations have adopted gender strategies, including UNAIDS , UNICEF Prospects for building more gender-responsive global health organisations will depend on change in the external political environment, organisational cultures and the strategies proponents adopt to pursue collective action and shape perceptions of the issue.Global health organisations will be more likely to prioritize gender if certain features of their external political environments shift, particularly the acceptance by influential states that improved population health and equity requires addressing gender inequality. This idea is in an early phase of the norm life cycle, having yet to reach a tipping point where a critical mass of states has fully embraced the norm, facilitating a cascade. Momentum is building, however: several of the conditions that facilitate norm emergence are already in place. High-level and effective norm entrepreneurs exist, such as Michelle Bachelet, former Chilean President and present head of the United Nations High Commissioner for Human Rights, and Helen Clark, former Prime Minister of New Zealand and former Administrator of the United Nations Development Programme. Organisational platforms are available, including UN agencies sympathetic to the agenda such as the United Nations Population Fund (UNFPA). Existing norms internalized by many states surrounding human rights present grafting opportunities, or opportunities for leverage. Gender and health is an issue that pertains to bodily integrity, an issue category that historically has resonated internationally. The surge of right-wing populism with a misogynistic bent represents a shock, inspiring social mobilization that may place pressure on states to shift policy. Moreover, there is both historical and recent precedent for the international diffusion of norms relevant to gender equality: the spread of women’s suffrage from the late 1800s through the 1900s, and more recently, the advance of norms on sexual and reproductive health rights and gender equality, facilitated by the 1994 Conference on Population and Development in Cairo and the 1995 Conference on Women in Beijing [The gender and health agenda will also depend on change in organisational cultures. Reform is difficult to enact because of the imprints of founding conditions within global health organizations. Committed top-level leaders are crucial. There is some precedent for leaders playing roles in pushing their organisations to prioritize gender: executive directors Nafis Sadik (1987-2000) and Babatunde Osotimehin (2010-2017) of the UNFPA, and Melinda Gates at the Bill and Melinda Gates Foundation have had such effects. Organisational culture change will also depend on the way professionals are socialized. In-house gender training may play some role, but even more crucial will be shifts in the ways medical schools, economics programs, and public health schools – the institutions that provide many of the professionals that staff these organisations – train their students. There is some evidence that change in training practices is occurring: many such schools are moving away from an exclusive technical and biomedical focus to recognizing the importance of integrating instruction on the structural, social, cultural, and economic forces that shape disease and illness patterns, including gender ,82.Finally, prospects will be shaped by the decisions gender proponents make regarding defining the issue and pursuing collective action. There are at least three challenges. One concerns problem definition: specifying precisely what the issues are, and how they should be addressed. A strength of the group of gender proponents is diversity. A tension to be managed is how to capitalize on this strength in ways that facilitate cohesion without sidelining voices. Striking a balance is challenging, but it may be facilitated by the global resurgence of right-wing politics, which provides an urgency to finding ways to manage differences and to act with unity.A second set of challenges pertains to positioning. Among the needs is the articulation of a clear set of demands. The danger in not having such clarity is that leaders of global health organisations will remain confused about what they are being asked to do to address gender. Another positioning challenge concerns the need to address tensions surrounding rights vs instrumentalist framings of the issue. Is it essential to stay true to the principles of human rights in framing the issue? Is the incorporation of economics and other kinds of arguments that may not align with the deeper beliefs of many proponents justifiable as a means of securing allies who may find such rationales more compelling than rights-based arguments? Can a balance be struck between principle-based and instrumental framing strategies? Beyond this, proponents will need to consider how specific problems pertaining to gender, such as violence against women, figure in their framing strategies. Here again is a tension: the agenda is broader than any one issue, yet some issues resonate more widely than others do. Should these issues be used as levers to generate attention, or does doing so marginalize other issues and detract from advancing the broader agenda?Finally, there is a set of challenges concerning governance. Proponents benefit from their capacity to attract a large, diverse coalition of actors. ICPD provides a historical example of diverse proponents concerned with reproductive health and gender equality effectively building a coalition to place their issues on global and national agendas . However


Chemical Breath presents two focused ethnographies that look at the relationship between young people and the inhaling of tobacco and synthetic cannabinoids. The first comes from a group of young people in Paris who smoke electronic cigarettes (e-cigarettes), who refer to themselves as “vapoteurs,” and the second comes from a group of young people in Makassar who smoke synthetic cannabinoids. The young people partaking in these popular practices value the social bonding they experience; they are also bombarded with social media messages encouraging the use of these products. And both face harms that may increase the precariousness of their lives: the Makassarian youth face imprisonment if discovered, and the health consequences of these synthetics are not fully understood. Similarly, the Parisian youth also risk lung damage, as vaping, while advertised as “safer” and sought out as a means to reduce the harms associated with cigarette smoke, exposes consumers to chemicals that either are understudied or known to be threats to health. The chapter concludes by pointing how these young people’s lives would benefit from sensible government regulation. James Monsees and Adam Bowen, two product design students at Stanford University, California, met each other while taking smoke breaks 15 years ago. Their failed attempts to quit inspired them to develop a vaping device that could help people stop smoking. Studying at a Silicon Valley university that encourages entrepreneurship, they soon set up their own company, Ploom, Inc. (later Pax Labs), where they designed a new slick device that worked by heating tobacco in a small, very hot oven, creating a vapor that could be inhaled. Monsees, CEO of Ploom, stated that the product offered a “premium luxury vape experience” . Being caught smoking cannabis in Indonesia is a serious crime that leads to imprisonment—possibly even the death penalty—while tobacco smoking is promoted heavily through advertising, and is highly acceptable (nearly the norm) for men. Our interlocutors in both settings sought to reduce harm, but they did so in different ways, and were encouraged in their efforts by different perceptions of risk. In this chapter, we also track the rising popularity of JUUL in US high schools among boys and girls who have not yet smoked regular cigarettes, and we show how JUUL hired young social media influencers to promote their product.There has been a surge in new inhalation devices in the past 20 years, which analysts suggest is related to the increased regulation of ordinary cigarettes Russel . In 2003New York Times reports an estimate that vaping products account for 30% or more of the business of the legal cannabis industry, pointing out that the products attractive alternatives to joints, because they don’t produce ash, are easy to hide, and don’t have a strong smell  and retains a buyer’s history. The vendors advised customers to first replace cigarettes with e-cigarettes, and then to gradually lower the amount of nicotine they were consuming. The vendors calculated the nicotine consumed via ordinary cigarettes (nicotine volume multiplied by the number of cigarettes smoked per day), and advised consumers how much nicotine was contained in the available e-cigarettes. Bevan’s young informants were well aware of the dangers of smoking, and even before they switched to e-cigarettes, they did all kinds of things to reduce risks, including using disinfectants to remove carbon monoxide from their hands and switching to organic tobacco. In this sense, e-cigarettes were a welcome replacement device for what were perceived as risky and toxic cigarettes Bevan .Bevan observes that, at least in Paris, taste was a key driver of vaping. Young people who smoked e-cigarettes compare their hobby to wine tasting and called themselves “flavor junkies”. Social gatherings where young people vaped together evolved into spaces of sensory exploration, as users passed e-liquids from hand to hand and shared experiences and tastes—the shared “gustatory pleasure” fostered feelings of community Bevan .Bevan  points tOn one side of a tartan picnic rug dappled in sunlight, a man asks quietly around him whether anyone else had changed weight when they had stopped smoking. He had put on 5 kg. What is he on? One man asks. Pausing to draw on an intricate wooden e-cigarette and exhaling a large cloud of apple and cinnamon vapor, he replies: 0 mg of nicotine. “It’s the nicotine, it makes you burn calories. It affects the brain,” a second man ventures. Well, he had had nicotine in it before and it made absolutely no difference, he was putting on weight anyway. The four of us shift position and recline to enjoy the now bearable late afternoon sunshine, slowly absorbing each other’s smoking histories, tales of transition and experience of e-cigarettes.Seated nearby in a circle in the shade, a larger group is leaning over a pile of small bottles of different colors, shapes and sizes. A woman in her forties is interested in how long e-liquids should be kept. The younger woman on her right answers “Officially, a year, but I think you can keep them a bit longer than that.” While passing around a plastic tub overflowing with homemade brownies, the group goes on to discuss their preferred brands of e-liquid and to question the traceability of e-liquid contents. The five members converge on a general aversion to Chinese liquids as lacking sufficient safety regulations. Bevan , p. 238In these vaping forums, users discuss a variety of issues, including technical issues related to the devices, such as a leaking or dead device, and laws and regulations. But conversations also include more personal concerns, such as having problems with one’s partner or wanting to lose weight. Health warnings are posted by members when news emerges on adverse effects of specific kinds of liquids or devices. One section of one of the forums announces in-person gatherings, called “vapodays,” and information about where they are to be held. Bevan describes a July “vapnique” (a combination of “ vape” and “picnic”) she observed in a city park in Paris:There was something missing from my life. And it’s funny, I felt like I wasn’t the same person anymore. I was sharing a flat with a friend, and strangely, when I stopped smoking, our relationship was a bit different. It was a bit tenser. Since I wasn’t smoking, we couldn’t share that moment together anymore. For me, smoking is a kind of sharing. When I had friends who quit, I was—I didn’t like it. I felt like I had lost something we had in common. Bevan , p. 237What stands out in Bevan’s ethnography is that one of the attractions of e-cigarettes was the social bonding that comes with the devices, bonding that was facilitated through social media. E-cigarettes allowed youth to experiment with different dosages of nicotine and align their vaping tastes to specific social settings and particular foods. Jem, a 25-year-old employee in a sports shop, explained that he had really suffered when he tried to quit smoking:An analysis by Euromonitor  notes thkretek). The lack of tobacco control policy is reflected in increasing smoking rates among men. In 2000, a reported 60% of adult men smoked, while in 2016 this percentage was up to 76%; in contrast only about 3% of women smoke in the country  with you.In Indonesia, cigarette smoking is ubiquitous among men, who often also smoke cannabis. One of the ChemicalYouth ethnographers, Akbar Alamsyah, described how a group of students from the University of Makassar often met to smoke cannabis together. Most of them started using cannabis out of curiosity, when they were still in high school. They touted its relaxing effects, while also pointing to its creative potentials. They consumed it mainly when hanging out with friends, and when they needed to, they pooled their money to buy it. Because it is a plant, they considered cannabis to be harmless and natural—a valuation that meshed with their experience that, while the substance caused them to feel mellow and relaxed, they didn’t “go out”  completely, as has happened with some of the other substances they have used. Some informants, though, said that they had experienced emotional turbulence and even paranoia when smoking cannabis. The effects, they explained, depend on whether the substance is “ sinte” in Makassar), which could easily be bought via Twitter or Instagram; just type the hashtag “#tembakausuper” (#supertobacco) into Instagram and you will see more than 100,000 posts from users and vendors.These interlocutors insisted that they really did not understand why cannabis was included in the list of narcotics in Indonesia, and they complained that heavy policing had driven up the price and that smoking cannabis was now more dangerous  than ever. They tried to conceal their use by blending cannabis with tobacco from commercial cigarettes, but feared being caught because of cannabis’s strong odor. For this reason, students used synthetic cannabis  Fig. .Fig. 3.4sinte contains ordinary tobacco  and synthetic cannabis . Sometimes synthetic flavors  are added, which add to its attraction.Our interlocutors explained that sinte, he was 18 years old and still in high school. He was watching basketball in a local park and his friend offered him a puff of what he thought was ordinary ganja (slang for marijuana). After the first puff, he asked his friend, “Why is it like this?” His friend replied that it was Temchin (a sinte imported from China). Bakasa really liked the effect: it worked faster than ordinary ganja.The first time Basaka, one of our key informants, used sinte user because his eyes are red and his lower eyelids are puffy. They said that the benefits of sinte are that it makes you feel relaxed and that you have fun with your friends. Another advantage is that is does not smell like ganja, so it is safer to use in public. But sinte also made some users feel nervous and they found it hard to communicate. As well, they could become thin, because it made them too lazy to prepare food and eat.Our interlocutors emphasized that you can recognize a sinte in the afternoons and evenings, when they have finished school or work, to relax and enjoy time together. It made them feel refreshed, even more so when they watched the sunset. The locations where they gathered to use sinte were relatively private spaces, such as rooms in their homes, cars, rooftops, and islands . Basaka hadn’t told his family members that he smoked sinte, as he was afraid they might judge him or confiscate his supply. He was also afraid of being arrested by the police. He did, however, confide in his niece, who he could tell by her reddish eyes, also was using sinte. She was also afraid of being arrested by the police.Usually Basaka and his friends smoked sinte from dealers they contacted via text message. In their communications, they used code words, for example asking “ada bahanmu?” (do you have stuff). They met the dealers in their homes, in the homes of friends, or on the street; this often involved taking some puffs together to gain the dealer’s trust. The process of ordering and consuming was also referred to as “having a snack.” The costs of sinte varied from 100,000 to 350,000 IRP (US $7–25) for a sachet, which can be used for six or so cigarettes—usually our interlocutors blended it into pre-rolled cigarettes to not make it look like a joint. Unlike ordinary cigarettes, sinte was shared, making it affordable for a group of friends. Basaka also said that he had bought it in bulk, making small sachets himself to make some profit to finance his own use.Our interlocutors bought sinte into cigarettes is a craft, one our interlocutors enjoyed doing. They tinkered with dosages to create the optimal effect. They each had their own preferred brands of cigarette tobacco with which they cut the sinte. Basaka preferred red of white Marlboros. Sampoerna (a kretek cigarette), which others used, was too sweet, he said. Some of his friend used menthol cigarettes as a base. To remake the cigarettes, after mixing tobacco with sinte, our interlocutors used rolling paper, which also came in different brands (and at different prices). Raw paper was more expensive, as it is made out of cannabis fibers. Marsbrand was cheaper, and therefore used more often. Sometimes the youth simply reused the paper of the cigarettes from which they took the tobacco. To these crafted joints they added a cigarette filter, to make inhaling easier. Or they rolled up tax-stamps found on cigarette boxes to make a filter. Others used pens or water bottles to help inhale the tobacco.Mixing sinte. He explained, “I want to keep having fun, but … it’s not good for my future.”Bakasi said he was tapering his use. He would smoke a joint if invited to by a friend, because smoking joints together was highly valued. But overall, he tried to avoid sinte in Jakarta:The gold-foiled packet that Jay holds up is small—about 10×10 cm—and innocuous-looking. You could stow it easily in your pocket, or your wallet. When opened, the contents seem similarly harmless. To the naked eye it looks just like ordinary tobacco, a familiar sight in a country of 61 million smokers. He takes a pinch or two from the packet and puts it on rolling paper. The resulting cigarette looks pretty much like a joint of marijuana. Sitting cross-legged on the floor of a dim apartment in Jakarta, he lights it up and takes a drag, and then another one. The effects are almost instantaneous, within a minute. His hands tremble, his eyes redden, and his body slackens. “Two drags are enough to get high,” he murmurs, his eyes half-closed. “Your head feels heavy and your body feels limp.” The high won’t last long, Jay says, maybe 20 or 30 minutes. He doesn’t want to take another drag, because he has seen what overuse looks like. “A friend of mine, it was as if he was possessed by a demon.” Convulsions, hallucinations, yelling. Jay’s friend … 30, says he experienced something similar when he had too much—7 drags to be exact. “I felt like I was possessed,” he says. “I started getting very aggressive, like I wanted to fight everyone.” … “When you smoke weed the effect is stable,” he says. “This synthetic stuff is not stable. It’s weird.”“When I smoke this, I feel like I’m being brought very high, and then not long after, I fall back down.”As a regular drug user, Jay says he’d prefer marijuana, which he says is cheaper and “healthier,” but that he buys super tobacco because of its convenience (“It’s so easy to get”) and its efficiency (“The high is so much higher”). Dwi, a marketing professional, holds up Jay’s unfinished joint. “Can I light this spliff first?” he asks. “To make it more soulful.” He takes a drag before speaking to us. Dwi, who like Jay uses drugs regularly, waxes a little poetic about marijuana, calling it God’s creation and comparing it unfavorably to the synthetic version.“You can be creative on weed, productive,” he says. “On this stuff,” he holds up the joint. “You’re just a consumer.” He adds that his heavy user friends refuse to smoke super tobacco because “it’s always a bad trip.” Like Jay, Dwi says that if he could choose between marijuana and super tobacco, he would pick the former. But these days with the marijuana supply dwindling, he’s smoking more of the latter, mainly because it’s so easy to get. “It’s just like ordering fast food.” Maharani Karina Maharani , a writesinte smokers are concerned about adverse effects, which is to be expected, according to Michael White, a professor of pharmacy at the University of Connecticut, who explains:There are several hundred synthetic cannabinoids in existence, and they all stimulate cannabinoid type 1 receptors (CB1), just like the active component in natural marijuana, THC, that provides the high. But they do so with different intensities and for differing periods of time. There is no way to know which synthetic cannabinoids are actually in the product you purchase. White Indonesian White explains further that natural cannabis not only contains THC but also has cannabidiol, which actually helps to temper the negative impact of THC. Synthetic cannabinoids do not contain cannabidiol. Moreover, they are often mixed with other chemicals, ranging from opioids to rat poison, which makes their effects even more unpredictable. It is unjust that, in an era when natural cannabis is being legalized in so many places in the world, our interlocutors in Indonesia were turning to more dangerous substitutes from unknown sources.Our ethnographic research suggests that the War on Drugs in Indonesia actually fueled the use of synthetic cannabis in Jakarta. Super tobacco was easy to get and was seen as safer by the young people who used it as a form of harm reduction. But, as the above observations suggest, adverse effects can be severe. Users cannot tell from the outside how much or what kind of synthetic chemicals have been sprayed onto the tobacco.sinte, which given the informal networks through which the products are distributed, will be hard for authorities to control.In 2019, Indonesian drug authorities made 25 synthetic cannabis compounds illegal (scheduled as Class 1 Narcotics), which means that drug enforcers are now free to crack down on the use and sale of synthetic cannabis. But our fieldwork suggests there will remain a high demand and continuous supply of new kinds of While quitting smoking appears to be an important reason to start vaping in France, in the United States, concern arose about the popularity of JUUL among youth who had never smoked before. A research project entitled “Stanford Research into the Impact of Tobacco Advertising,” based at the Stanford University School of Medicine, connected the surge in the e-cigarette’s popularity to JUUL’s marketing strategy, which was emphatically youth oriented. Its “Vaporized” campaign, which started in 2015, featured male and female models in their 20’s in casual dress, along with bright colors. The researchers note that “the central message seems to be that if you try JUUL you will be blown away  by the wonderful new vapor product” , arguing that to encourage people to quit smoking:The report reviews evidence on potential harm from SNP and concludes that public health researchers and medical professionals who warn against e-cigarettes mislead the public by adhering to the precautionary principle. The authors argue that that position is misguided, because “there is a potentially huge saving in mortality and morbidity to be made by actively encouraging persistent smokers to switch to SNP,” and that there is a danger from the “global drive to over-regulation and control” Shapiro , p. 77.Journal of the American Medical Association argues that flavorings are “a largely unrecognized potential hazard”  suggest that vaping is a safer administration route, given it avoids the tar and other toxins associated with the burning of tobacco leaves, many medical specialists have raised concern about the safety of the adjuvants and flavors included in e-cigarette liquids and pods. A 2014 contribution to the As of the writing of this chapter in 2020, five years after the early warnings of harms associated with vaping chemicals were reported, JUUL is front-page news following an outbreak of severe lung illnesses which has left 1479 people sick and 33 dead. The health authorities found that the e-cigarettes that caused the illnesses contained THC Ritchel , and thaRecognizing these problems, JUUL’s chief executive, K.C. Crosthwaite, said in a statement, “We must reset the vapor category by earning the trust of society and working cooperatively with regulators, policymakers, and stakeholders to combat underage use, while providing an alternative to adults smokers” Wells , p. 1. Asinte products used by our respondents in Makassar, this would appear to be a safer alternative. Indeed, medical evidence suggests that vaporizing cannabis is safer than combustion, as the temperatures reached in vaping devices are lower, which means that fewer carcinogens and irritants are produced and inhaled  are very high in the country (Philippines CNN While Blokhuis’s compliance with the global treaty on tobacco control is commendable, he may appear to be missing an important new trend. A survey of a representative sample of 6718 youth in the Netherlands found that 36% of 16-year-old youth and 39% of 15-year-old youth had tried an e-cigarette (Utrecht University While global health policymakers have joined forces in the FCTC to reduce harm from nicotine addiction, our ethnographic research shows that many youth are engaging with these novel devices, which can be used as substitute for ordinary cigarettes. It is worrying that despite declaring a commitment to promoting e-cigarettes to adults, for the purpose of quitting ordinary cigarettes, companies are targeting youth through social media. It is also worrying that the products contain a wide variety of flavors and active ingredients, the safety of which has not been sufficiently studied, and that regulators appear to be taking for granted manufacturers’ claims that e-cigarettes are a safe alternative to smoking tobacco.British Medical Journal. They conclude that because no long-term research on toxicity has been done in humans, it is too early to say “with certainty” that e-cigarettes are safer. Their review found that e-cigarettes can cause increased symptoms of respiratory disease and negatively affect lung physiology and immune function. Gott, who is a pulmonologist at the University of California San Francisco, is quoted in New York Magazine as stating:People are conducting a huge experiment on themselves about what kind of lung disease you can produce from all these different chemicals that you’re putting into the lungs. … And the bulk of the evidence is increasingly that these devices have new and unpredicted toxicity. Hall It seems a ripe time to apply the precautionary principle to this new chemical market, as also suggested by Gotts and colleagues , who recWe propose that tobacco control programs start discouraging the use of e-cigarettes as a means to quit smoking, as there are better methods to quit smoking with proven success. We also propose that programs that seek to achieve a “smoke-free generation” expand their scope to discourage the use of e-cigarettes as well. This is even more urgent now the world is confronted with COVID-19, a viral disease that causes serious lung disease. The US NIDA warns youth “Now more than ever, it’s important to be smart about your health. Take care of your lungs: Avoid smoking or vaping any substance” NIDA , p. 1.sinte as an alternative to smoking cannabis, a message that is likely to be understood in Indonesia, as our interlocutors recognized the potency and health risks of substitution products. A challenge in such health education messages is that social media are full of positive accounts of vaping and sinte, which raises the question: How should we regulate online marketing of products to prevent harm? We think one way is to engage youth who act as influencers, and hope that they are willing to share cautionary tales.Similar educational efforts are needed to discourage the use of This chapter provides insights into how young people seek substitutes to mitigate the risks of smoking cigarettes and cannabis. The harms that they seek to avoid differ. In the focused ethnography conducted in France, young people seek to avoid the risks of inhaling cancer-causing chemicals via cigarettes, while in Indonesia they fear being incarcerated because of being caught smoking cannabis. Harm reduction programs tend to overlook such substitution practices by youth. As we elaborate in Chapter 10.1007/978-3-030-57081-1_9, they tend to be designed to prevent harmful practices, one chemical at a time (Hardon and Hymans Young people share their experiences with substitutes both face-to-face and online. Our ethnographies show how these interactions tend to amplify the beneficial potentials of the new products, especially when youth are encouraged to do so by manufacturers’ deliberate marketing strategy, as we illustrated in the case study on JUUL.We describe in this chapter how tobacco companies “re-inform” Barry  their prImogen Bevan is a social anthropologist at the University of Edinburgh. She has carried out ethnographic research in France on smoking and vaping, and in Scotland on sugar consumption and the social meanings of sugar. As a researcher for the ChemicalYouth project, Imogen examined young people’s lived experiences of smoking and e-cigarette use, and the socialities that emerge through non-medicalized forms of substitution. Her study used sensory and creative visual methods to explore what these technologies and substances might do for their users in social context. Imogen’s research interests include the anthropology of the body, morality, and kinship; the boundaries between food, drugs, and medicine; sensory anthropology; and visual methods Fig. .Fig. 3.7Akbar Alamsyah was a researcher for the ChemicalYouth project and conducted fieldwork on synthetic cannabis smoking practices amongst students in Indonesia.In Chapter 10.1007/978-3-030-57081-1_1 we explain in detail what informing chemicals entails. We borrow this concept from Barry  who argu