Abstract
Asian Americans (AA) and Pacific Islanders (PI) are an understudied population for health and tobacco use, which is alarming for a fast growing U.S. population. Research in smoking among AA and PI college students is limited, despite 50% of AA and 20% of PI having obtained a college degree. A cross-sectional tobacco survey was administered in a large racially diverse Southern California university (N = 490) that examined smoking behavior, psychosocial, and perceptual factors related to smoking among AA and PI compared with Caucasians. Overall, 19% of participants were smokers. The prevalence of current smoking by race was 26% PI, 19% AA, and 17% Caucasian. AA and PI are light, infrequent smokers who smoke mainly for social reasons and in social locations. Most AA and PI made quit attempts and reported intention to quit smoking. Low to moderate risk perceptions for addiction, disease and difficulty in quitting were observed. Social norms center on family influences, therefore it is recommended that cessation approaches target cigarette smoking norms within this social environment to increase perceptual risks of smoking. Smoking cessation should be placed in college health outreach programs based on culturally tailored approaches for AA and PI that target their unique smoking characteristics.
Tobacco use remains the leading cause of preventable death among all racial groups in the United States (U.S. Department of Health and Human Services [USDHHS], 2010). Smoking among younger adults (18-25 years old) has slightly declined since 2005 and remains a public health problem (Centers for Disease Control and Prevention [CDC], 2011). College students represent a group of younger adults who are malleable to their social environment (Otsuki, Tinsley, Chao, & Unger, 2008) and are vulnerable to peer influences of cigarette smoking (USDHHS, 2012). Despite notions that education is inversely related to tobacco use, college smoking remains stable (Rigotti, Lee, & Wechsler, 2000). Furthermore, smoking prevention and intervention programs on college campuses are almost nonexistent (Wechsler, Kelley, Seibring, Kuo, & Rigotti, 2001).
College student smoking has predominately examined Caucasian students and research on minority populations has historically combined racial groups, such as Asian Americans (AA) and Pacific Islanders (PI; Bowen & Kurz, 2012). AA constitute a majority of minority students attending college with more than 50% of AA having obtained a baccalaureate degree; moreover, 20% of PI have also graduated college (U.S. Census Bureau, 2010). Prevalence of smoking has been inconsistently reported among AA and PI (16% to 22%) and recently AA have been identified having the fastest increase of smoking in the United States (Ma, Fang, Tan, & Feeley, 2003; Tobacco Control Evaluation Center, 2011). Therefore, a more thorough examination of smoking behavior in the AA/PI college population is encouraged.
AA and PI have often been described as light smokers, with low smoking prevalence and fewer cigarettes per day compared with other groups (Tong, Nguyen, Vittinghoff, & Pérez-Stable, 2009). This has contributed to the myth of the model minority, in which they are viewed as having superior health outcomes compared with other minority groups. Furthermore, this viewpoint purports that light smoking does not warrant aggressive tobacco control interventions and is not a public health problem (Chen & Tang, 2007).
Despite the model minority viewpoint, AA and PI suffer a disproportionate risk for cancer, constituting a major health disparity. Cancer is the leading cause of death for AA and PI, compared to cardiovascular disease for other racial groups (American Cancer Society, 2008; CDC, 2010; Chen & Tang, 2007). Using tobacco is a primary risk factor for developing cancer, thus smoking for AA/PI has a greater risk for tobacco-related morbidity and mortality (American Cancer Society, 2008). No safe dose of cigarette smoking exists and any smoking increases risk for mortality and morbidity. Males appear to have higher smoking prevalence compared with females (Chen & Tang, 2007), but apart from gender differences, variations of smoking behavior and characteristics may exist. Examination of separate racial groups is warranted to gain a better understanding of how to promote cessation (Otsuki, 2009).
AA and PI share similar cultural values where the norm centers on the family (Ma et al., 2003). Familial influence is a key factor in shaping social normative beliefs, and cultural factors may influence attitudes about tobacco use as well as sustain use. AA and PI may have greater familial influences than other racial groups (Tobacco Control Evaluation Center, 2011). Despite similarities, AA and PI constitute two diverse racial groups that are usually described as a broad racial category, which may not capture heterogeneity of tobacco use (Hsia & Spruijt-Metz, 2007). More attention to cultural influences is needed in AA and PI to determine if culturally tailored methods of health promotion have an effect on smoking behavior.
Little is known about characteristics of individual smoking behavior, role of the social environment, and smoking maintenance among AA and PI (Otsuki et al., 2008). Past research of smoking found less favorable attitudes and lower awareness of health consequences (Ma et al., 2003). Motivation to quit has been explored, and AA and PI are more likely to quit but less likely to refrain from smoking relapse compared with Caucasians (Bowen & Kurz, 2012). Because AA and PI are characteristically light smokers with low nicotine dependence, psychosocial characteristics of smoking may be meaningful in understanding smoking behavior (Tong et al., 2009). Self-efficacy can be a strong predictor of behavior change but has not been specifically examined in AA and PI in response to smoking (Martinelli, 1999). Reasons and locations for smoking appear to be important, as the dynamic role of the social environment may influence college smoking (Otsuki et al., 2008). Finally, social normative beliefs will be key to understanding interpersonal influences on smoking behavior.
Given the national failure to reduce smoking among young adults (Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, 2012) and limited research in the AA and PI populations on smoking behavior, research is required. For successful smoking prevention and cessation programs to be developed for college health promotion, targeted information about these racial groups is needed. The purpose of this study was to examine smoking behavior and related psychosocial and contextual environment variables among AA and PI college students. The theoretical framework used was based on the social cognitive theory, postulating an existing interaction between personal and cognitive characteristics of individuals, environmental influences, and behavior (Bandura, 2006). By measuring various psychosocial factors, variables can be identified and targeted to reduce and prevent smoking behavior. Also, quit behaviors, perceptions, and perceived risks of smoking were examined. A comparison group of Caucasian college students was used to further contrast racial differences using a reference group.
Methods
Design and Sample
Data were derived from a larger study of undergraduate college students (N = 490) at a large Southern California public university. This university was selected because it is racially diverse that includes roughly 21% AA/PI and 29% Caucasian students. This site is representative of other large universities that are Asian American and Native American Pacific Islander–Serving institutions (U.S. Department of Education, 2013). The present study focuses on the subset of undergraduate students (n = 287) who identified as AA or PI (N = 139), as well as a Caucasian comparison group (n = 148). Participants who identified as any race other than AA, PI, or Caucasian were excluded from this study. The study was a cross-sectional design using a paper-based survey. Approval was obtained from the university’s institutional review board. Analysis included only those 18 to 25 years old (M = 21 years, SD = 2).
Procedures and Measures
In the fall semester of 2009, the study survey was administered in undergraduate courses across all disciplines and locations on campus. Prior to participation, informed consent was obtained. Survey items were developed based on national instruments (CDC, 2010; Substance Abuse and Mental Health Services Administration, 2008) and key smoking descriptors to examine current smoking behavior included smoking frequency in the past 30 days, number of days smoked and cigarettes smoked per day. Intention to continue to smoke or quit smoking, quit attempts, and consideration of self as a smoker or social smoker were examined. Risk perceptions were assessed by rating the degree of perceived risk on a 10-point scale (0 = no risk to 10 = high risk) and based on perceived risk for developing a smoking-related disease, becoming addicted to smoking, and difficulty in quitting smoking (Cronbach’s α = .84).
The psychosocial variables measured were self-efficacy to resist smoking, perception of social pressures to quit smoking, and perceived benefits of smoking. The 17-item self-efficacy was adapted from existing measures and was rated from 1 to 10, with higher scores indicating higher degree of confidence to abstain from smoking cigarettes in various situations (Bandura, 2006; Etter, Bergman, Humair, & Perneger, 2000) and had high internal consistency (Cronbach’s α = .96). Ten items for the perception of social pressures and benefits of smoking scale were rated on a 6-point Likert-type scale adapted from existing measures (1 = strongly disagree to 6 = strongly agree; Primack, Switzer, & Dalton, 2007) and had an acceptable internal consistency (Cronbach’s α = .79) and assessing perceptions of the benefits of smoking (Cronbach’s α = .86). Perceived norms of peer smoking behavior were assessed by asking perceived prevalence of smoking behavior among peers.
Situational and behavioral information related to contextual environment for smoking was measured using multiple items that asked location(s) and context of smoking and reasons for smoking. In addition, past month alcohol use and past week binge-drinking behavior, defined as five or more drinks at a sitting, was measured.
Classification of smoking groups
Current smokers were classified based on reporting smoking any cigarettes in the past 30 days (CDC, 2009) and this is a standard method of smoker classification in national surveys. Nonsmokers included those who had never smoked a single cigarette and those who have ever tried smoking but did not report any smoking behavior in the past 30 days.
Analytic approach
Categorical data were summarized using crosstabs and Pearson chi-square was used to test significant differences. Independent-samples t tests were used to obtain descriptive statistics and evaluate differences between smokers and nonsmokers and between males and females on continuous variables. These analyses were adequately powered at .80 to detect medium effect sizes at the .05 level (n = 102 required; Faul, Erdfelder, Lang, & Buchner, 2007). One-way analysis of variance was used to obtain descriptive statistics and evaluate differences between ethnic groups of smokers on continuous variables. These analyses were adequately powered at .80 to detect large effects at the .05 level (n = 51 required; Faul et al., 2007). Follow-up tests were conducted to evaluate pairwise differences among means, using the Bonferroni adjustment for multiple comparisons. All analyses were conducted using SPSS Version 20.
Results
Participants and Smoking Policies
The majority participants were female (70%), never married (96%), and the demographics of the sample were comparable to the university, with 33% AA, 15% PI, and 52% Caucasian (see Table 1). The mean age was 21 years for all participants and 31% were of senior class standing. Most students (96%) reported residing off-campus; many with parents (69%) and 26% of students reported living with someone who smokes. Most students (76%) reported that there were smoking restrictions on campus, although only 17% stated that students adhere to smoking restrictions. Students were fairly divided on preferred smoking policy, with 47% favoring designated smoking areas and 38% preferring a completely smoke-free campus (see Table 2).
Study Demographics
Comparison of Social and Perceptual Variables Between Smokers and Nonsmokers
0 (0 days) to 6 (all 30 days)
0 (none) to 7 (at least 24; more than 1 pack).
0 (never used) to 4 (used all 30 days).
0 (none) to 7 (all 7 days)
p < .05. **p < .01.
Smoking Behavior
Overall, 19% of the sample was classified as smokers. The rate of smoking appeared higher among PI (26%) compared with AA (19%) or Caucasian (17%); however, the difference was not statistically significant, χ2(2) = 1.65, p = .439. Males (26%) were more likely to be classified as a smoker than females (16%), χ2 (1) = 4.75, p < .05. The average age of smoking initiation was 15 years, with a range of 7 to 22 years and the modal age was 18 years. Many current smokers were light or infrequent smokers, with 48% smoking fewer than 2 days per month and 46% smoking less than 2 cigarettes per day. No gender or ethnic differences were found (see Table 3).
Smoking Characteristics and Social and Perceptual Variables by Race and Gender
NOTE: Entries with boldface letters indicate the following:
10-point scale (0 = no risk or difficulty to 10 = high risk or difficulty).
1 (strongly disagree) to 6 (strongly agree).
0 (cannot resist smoking at all) to 10 (highly certain I can resist smoking).
0 (0 days) to 6 (all 30 days).
0 (none) to 7 (at least 24; more than 1 pack).
0 (never used) to 4 (used all 30 days).
0 (none) to 7 (all 7 days).
A majority of smokers reported they intend to quit smoking completely (83%) and 77% believe they can quit anytime. Furthermore, 67% think they will not be smoking in the next five years. Intention to quit was significantly different by ethnicity, with PI (100%) and Caucasians (84%) reporting the highest intention compared with AA (61%), χ2(2) = 9.35, p < .01. Among AA, significantly more males (50%) reported an intention to quit completely than females (11%), χ2(1) = 7.90, p < .01. In contrast, more Caucasian females (65%) than Caucasian males (26%) reported an intention to quit, χ2(1) = 4.11, p < .05. Approximately half of the smokers had made previous quit attempts (52%), with significantly more attempts made by AA males (50%) compared with AA females (11%), χ2(1) = 7.90, p < .01. AA (61%) and PI (55%) were more likely to identify as a smoker than Caucasians (16%), χ2(1) = 10.39, p < .01.
Smokers and Nonsmokers on Social and Perceptual Variables
Factors that were associated with smoking status among participants (see Table 2) were higher perceived peer smoking frequency in the past 30 days, t(199) = −2.89, p < .01 and higher cigarettes per day smoked on the days they smoke, t(277) = −4.79, p < .001 compared with nonsmokers. In addition, smokers reported more alcohol consumption in the past week, t(194) = −7.52, p < .001 and more frequent binge drinking, t(115) = −4.02, p < .001 than nonsmokers. Smokers (33%) appeared somewhat more likely than nonsmokers (25%) to live with someone who smokes; however, this difference was not significant, χ2(1) = 1.74, p = .189 (see Table 1).
Social and Contextual Environment Smoking Variables
Most participants did not identify as a smoker (61%), although many consider themselves social smokers (72%) and smoke more often on the weekends (59%). The most common locations for smoking were at parties (65%), friend’s houses (50%), and bars (50%). Top reasons for smoking included drinking or when drunk (63%), when stressed or to relieve anxiety (59%), and to relax (50%). There were no differences found in social and contextual environment smoking variables and quit behaviors between AA, PI, and Caucasians.
Psychosocial and Perceptual Variables by Race and Gender
Table 3 displays social and perceptual variables among smokers by race and gender. In general, smokers perceive moderate risk of disease from smoking (M = 4.31, SD = 3.25). AA reported a significantly higher perceived risk of disease than Caucasians, F(2, 49) = 4.16, p < .05. Additionally, Caucasian females reported a higher perceived risk of disease than Caucasian males, t(21) = −2.65, p < .05 (see Table 3). Given racial and gender differences on perceived risk of disease, an interaction was tested and it was not significant.
In general, smokers perceived low risk of addiction (M = 3.10, SD = 3.21) and low difficulty quitting smoking (M = 3.19, SD = 3.45). AA reported a significantly higher perceived risk of addiction than Caucasians, F(2, 49) = 3.48, p < .05 (see Table 3). Although not significantly different, AA rated perceived difficulty to quit smoking double that of PI and Caucasians. Perceptions of social pressure to quit (M = 3.84, SD = 1.28) and benefits of smoking (M = 4.12, SD = 1.38) were generally moderate. Self-efficacy to resist smoking was moderately high (M = 6.99, SD = 2.16). There were no further significant race or gender differences.
Caucasians (88%) and PI (82%) were more likely to respond affirmatively to the question of whether there were any smoking restrictions on campus than AA (56%), χ2(2) = 6.29, p < .05. Smokers tended to perceive that peers smoked more than 2 days per month and this appeared most pronounced among PI (M = 4.73, SD = 1.56) compared with Caucasians (M = 3.21, SD = 3.70), F(2, 50) = 3.83, p < .05, although the post hoc test did not reach significance (see Table 3).
Discussion
This study sought to examine cigarette smoking among AA and PI college students, with a Caucasian reference group. We found that smoking among college students occurs at a higher prevalence (19%) than the rates reported in national surveys (11%; California Health Interview Survey, 2007). Cigarette smoking prevalence appeared higher among PI than AA and Caucasians, although no significant differences between racial groups were found. The most frequently reported age for smoking initiation was 18 years; thus smoking initiation begins in college. Less than half of all participants preferred smoking restrictions or a smoke-free campus and AA were significantly less affirmative on whether there were any smoking restrictions on campus. Furthermore, a small proportion of all participants believed that smoking restrictions on campus were adhered to, although most knew smoking restrictions exist. Consistent with past research, most AA and PI college student smokers were light and infrequent smokers (Bowen & Kurz, 2012), smoking less than two cigarettes per day on the days they smoke, and smoking fewer than 2 days per month. Smokers perceived significantly higher peer smoking behavior and alcohol consumption than did nonsmokers, suggesting social normative beliefs developed by peer modeling may be an overestimation of peer behavior (Kear, 2002).
More than half of smokers did self-identify as a smoker, although almost three quarters of the smokers self-identified as social smokers and environmental and contextual smoking trends were consistent with this (Berg et al., 2009). Specifically, a majority of smokers reported smoking only on the weekends and rated smoking in social settings most (Colder et al., 2006). More than half of all smokers reported smoking primarily when drinking or drunk, which correlates with alcohol and cigarette use (Emmons, Wechsler, Dowdall, & Abraham, 1998). Furthermore, the social environment appears to play a role in influencing smoking behaviors among current smokers (Ridner, 2005). Almost 60% of smokers reported smoking to relieve stress and anxiety and to relax, although it is not known if this occurred within social contexts.
Half of all smokers attempted to quit smoking completely and intention to quit smoking was substantially higher between PI and Caucasians compared with AA. Interestingly, AA males reported a significantly higher intention to quit smoking than AA females, whereas the opposite was found in Caucasians with females reporting higher intention to quit. This is in contrast to Bowen and Kurz (2012), who found that AA made less quit attempts than Caucasians. While half of all smokers reported making a quit attempt, AA male smokers had made significantly more attempts than AA female smokers. The majority (83%) of smokers believed in their ability to quit smoking at anytime and that they would discontinue smoking in the next 5 years. This was in contrast to Moran, Wechsler, and Rigotti (2004), who found that self-identified social smokers reported fewer quit attempts and less intention to quit smoking. Last, supported by Thompson et al. (2007), college student smokers do attempt to quit smoking and find it more difficult to quit smoking than anticipated, which may explain why AA males reporting higher intention to quit and more frequent quit attempts.
Overall, smokers had very low perceptions of risk for addiction, while difficulty in quitting smoking and developing a smoking-related disease were rated more moderately. AA had a significantly higher perceived risk of disease and risk of addiction compared with Caucasians. AA also reported a twofold greater perceived difficultly to quit compared to both PI and Caucasians, although it was not significantly different. Perceptions of the pressure to quit smoking were rated moderately to low, this reflects social normative beliefs that smoking might be reinforced by the willingness to comply to peer smoking patterns to maintain social accord (Otsuki et al., 2008). Perceptions of smoking benefits were rated low; however, perceived meanings of smoking may not reflect the actual determinants of smoking (Hsia & Spruijt-Metz, 2007) and smokers may not perceive benefits as high but smoke for reason that are beneficial to them. Resistance self-efficacy to not smoke was moderately high among all racial groups, which can be a strong predictor of behavior and may have a buffering effect on smoking (Martinelli, 1999).
Limitations
Although we attempted to recruit a diversity of participants, caution must be used in generalizing results to all college students due to the small sample size and utilization of a convenience sample. Replication with a larger sample of smokers with better representation of all racial groups, including dividing AA subpopulations, is recommended. We did not distinguish former smokers among those who had ever tried smoking in the nonsmoker group; therefore the proportion of former smokers is not known. Also, we did not utilize measures of acculturation or have items related to culture and infer recommendations from evidence-based practices. Finally, the study used self-report data, which did not include a biochemical validation of reported smoking behavior and is subject to recall bias and error.
Conclusions and Implications
Cigarette smoking initiation is occurring in late adolescence and when entering college (Everett & Husten, 1999). This implies that smoking cessation would be appropriately placed in college health outreach programs. This study extends current U.S. population trends about light and infrequent smoking to AA and PI college students (USDHHS, 2012). Our findings indicate that AA and PI college smoke primarily smoking in social situations and for social reasons, in addition there are psychological factors (e.g. stress, anxiety, and depression) that appear important for smoking rather than smoking frequency. This is an important area for additional research and may have implications for how smoking cessation interventions are delivered.
Many AA and PI college students are attempting to quit smoking and intend to quit and not be a smoker in the future. AA appear to be more motivated to quit and make more frequent quit attempts. Resistance self-efficacy to not smoke bodes well for cessation efforts and practitioners can continue to increase confidence to resist smoking in various situations. Social normative beliefs need to be targeted for cessation, including perceptions related to smoking norms, increasing perceived risk, and smoking policy awareness. Practitioners should address the strong familial influence on perceived norms among AA and PI and attempt to involve the family with cessation efforts as part of a culturally tailored cessation program. Cessation programs should assist quitting and provide resources that will promote smoking abstinence and include educational and skill-building strategies.
A combination of efforts is needed to change cigarette-smoking behavior among the AA/PI college population. Tobacco prevention could result from increasing awareness of smoking restrictions on campus and providing better enforcement to improve adherence to campus smoking policies. The college population represents a high proportion of AA/PI and college is an ideal setting and opportune time for cessation efforts for targeting smoking cessation and reducing health disparities.
Footnotes
Acknowledgements
The first author would like to acknowledge the following individuals for their contributions to the research design and project implementation: Drs. Helen Hopp Marshak, Joyce W. Hopp, and Emmanuel Rudatsikira.
Both authors would like to acknowledge student researchers, Azucena Vasquez, Brittany Basora, Jonathan Volden, and Cassie Volpe, for their contribution to literature review.
Supplement Note:
This article is published in the supplement “Promising Practices to Eliminate Tobacco Disparities Among Asian American, Native Hawaiian and Pacific Islander Communities,” which was supported by the Asian Pacific Partners for Empowerment, Advocacy and Leadership (APPEAL) through CDC Cooperative Agreement 5U58DP001520.