Cultural and Social Influences on Adolescent Smoking Dissipate by Emerging Adulthood Among Hispanics in Southern California

J Immigrant Minority Health DOI 10.1007/s10903-013-9910-9 ORIGINAL PAPER Cultural and Social Influences on Adolescent Smoking Dissipate by Emerging Adulthood Among Hispanics in Southern California Jon-Patrick Allem • Daniel W. Soto • Lourdes Baezconde-Garbanati • Steve Sussman Jennifer B. Unger • Ó Springer Science+Business Media New York 2013 Abstract The aim of the present study was to identify risk factors for smoking among Hispanic adolescents and determine whether these factors continued to influence smoking into emerging adulthood. Data were drawn from 932 Hispanics in the greater Los Angeles area who were surveyed in high school in 2007 and then again in emerging adulthood from 2010 to 2012. Logistic regression assessed the associations between predictors in adolescence and smoking in adolescence while an order one transition logistic model assessed predictors in adolescence and smoking in emerging adulthood. Adult and sibling smoking status, perceptions of smoking, perceived discrimination, and fatalism all influenced smoking in adolescence but not in emerging adulthood. Once Hispanics reach emerging adulthood different tactics to reduce smoking will be needed and are where future research should be directed. Keywords Hispanic
Emerging adults
Adolescence
Smoking Background The Surgeon General has set a high priority on reducing the smoking prevalence among emerging adults as currently one in three smoke in the United States [1]. Among emerging adults, Hispanics appear to be at high risk for smoking. In 2011, 28.4 % of Hispanic emerging adults J.-P. Allem (&)
D. W. Soto
L. Baezconde-Garbanati
S. Sussman
J. B. Unger Department of Preventive Medicine, Keck School of Medicine of USC, 2001 N. Soto Street, 3rd Floor Mail, Los Angeles, CA 90032, USA e-mail: allem@usc.edu aged 18–25 reported cigarette use in the past month compared with 25.7 % of African Americans and 10.1 % of Asian Americans [2]. Currently, there is limited understanding of the risk factors for smoking among Hispanic emerging adults. A reasonable starting point for structuring this literature would be to build on studies of adolescents [3]. Because many risky behaviors are developed during adolescence, it is important to understand whether or not the factors that influence smoking during adolescence continue to influence smoking during emerging adulthood. If influences dissipate by emerging adulthood, prevention scientists should identify new, more proximal influences on smoking that emerge post-adolescence. Because the smoking prevalence among Hispanic emerging adults has not declined as considerably as among other priority populations, [1] it is possible that proximal factors in emerging adulthood are not fully understood, leaving a gap in the prevention literature. The present study investigated whether cultural and social influences on adolescent smoking persist into the future by surveying respondents in high school and several years later as emerging adults. Conceptual Framework Cultural risk factors for smoking among Hispanic adolescents include parent–child Hispanic acculturation discrepancy [4], fatalism, or a general belief that one’s outcomes are predetermined [5], and perceived discrimination [6, 7]. While previous studies showed clear associations in adolescence, it is unknown whether these factors continue to influence smoking in emerging adulthood. In addition to cultural influences, social influences also affect smoking. These include descriptive norms, or perceptions of what most others do [8, 9], and injunctive norms or perceptions 123 J Immigrant Minority Health of what most others approve or disapprove [10]. Data restrictions prevented this study from testing hypotheses about all known social influences of smoking. However, parental or adult smoking models [11, 12], as well as sibling smoking status [13, 14] have been shown to influence smoking. The present study tested whether or not these cultural and social influences were associated with smoking among Hispanics, thus achieving two research aims: adding recommended clarity to the role of social influences on smoking among Hispanic adolescents [15], and informing the literature on Hispanic emerging adults. Methods Participants and Data Collection Surveys were completed by individuals who participated in Project RED (Retiendo y Entendiendo Diversidad para Salud) [4]. Project RED is a longitudinal study of acculturation patterns and substance use among Hispanic adolescents in Southern California. Adolescents were enrolled in the study when they were in 9th grade, attending seven high schools in the Los Angeles area. Schools were invited to participate if 70 % or more of their student body was Hispanic, as indicated by data from the California Board of Education. Details of the school and student recruitment process are described elsewhere [4]. In 2005, all 9th-graders attending selected schools were invited to participate in the survey (n = 3,218). The 9th grade survey (Year 1) was administered in the Fall of 2005, the 10th grade survey (Year 2) in the Fall of 2006, and the 11th grade survey (Year 3) in the Fall of 2007. For the school-based survey in 9th, 10th, and 11th grade, data collectors distributed surveys to all students who had provided parental consent and student assent. The university’s Institutional Review Board approved all procedures. Students who self-identified as either Hispanic, Latino or Latina, Mexican, Mexican–American, Chicano or Chicana, Central American, South American, Mestizo, La Raza, or Spanish on survey items asking students to indicate their ethnic identity were later surveyed in emerging adulthood from 2010 to 2012. Research assistants sent letters to respondents’ last known addresses and invited them to visit a website or call a toll-free phone number to participate in the study. If participants could not be contacted with the information they had provided in high school, staff searched for them online using publicly available search engines, as well as social networking sites. Respondents with complete data in 11th grade served as the sample of adolescents (n = 1,341). Respondents with complete data in 11th grade and in emerging adulthood, served as the sample of emerging adults (n = 932). Those 123 lost to follow-up were more likely to be male (p \ .05), had larger parent–child acculturation discrepancy scores (p \ .05), perceived less smoking in high school on average (p \ .01), and were more likely to have a sibling who smoked in high school (p \ .01) but did not statistically significantly differ on age, smoking behaviors or the other explanatory variables (e.g., adult/parental smoking status, fatalism, perceived discrimination, perceived approval for smoking). Measures Participants’ acculturation scores and their perceptions of their parents’ acculturation were used to compute parent– child Hispanic acculturation discrepancy scores. Further details on this measure can be found elsewhere [4]. Perceived discrimination was adopted from previous research [16]. Respondents were prompted with the statement, ‘‘Sometimes people feel that they are treated differently because of their ethnic or cultural background. How do people treat you?’’ and then were shown a series of statements including, ‘‘You are treated with less respect than other people,’’ ‘‘You are treated with less courtesy than other people,’’ ‘‘People act as if they think you’re not smart,’’ ‘‘People act as if they’re better than you,’’ ‘‘You receive poorer service than other people at restaurants or stores,’’ ‘‘People ignore you or act as if you are not there,’’ ‘‘You are threatened or harassed,’’ ‘‘You or your family members are called names or insulted,’’ ‘‘People act as if they think you are dishonest,’’ ‘‘People act as if they are afraid of you.’’ Response were coded as ‘‘often’’ = 1, ‘‘sometimes’’ = 2, ‘‘rarely’’ = 3 and ‘‘never’’ = 4. Responses to individual items were averaged with Cronbach’s alpha = 0.90. Fatalism was also adopted from previous research [17]. Participants were asked, ‘‘It’s more important to enjoy life now than to plan for the future,’’ ‘‘People can’t really do much to change what happens in life. You just have to accept things,’’ ‘‘I live for today because I don’t know what will happen in the future,’’ ‘‘I don’t plan ahead because most things in life are a matter of luck.’’ Responses were coded ‘‘Definitely No’’ = 1 ‘‘Probably No’’ = 2 ‘‘Probably Yes’’ = 3 ‘‘Definitely Yes’’ = 4. Responses to individual items were averaged with Cronbach’s alpha = 0.79. Descriptive norms, perceptions of what most others do, was measured by responses to the question ‘‘Think about 100 students in your grade who are the same gender as you (boy or girl). Guess how many of them smoke cigarettes at least once a month.’’ Responses were treated as continuous. Injunctive norms were measured by responses to the question ‘‘How would your five closest friends feel about you if you smoked one or more packs of cigarettes a day?’’ Responses were dichotomized with a 1 indicating perception of approval. J Immigrant Minority Health Adult smoking status was measured by responses to the question ‘‘Think of the two adults that you spend the most time with. How many of them smoke cigarettes every day or most days?’’ Responses were dichotomized with a 1 indicating having an adult who smokes. Sibling smoking status was measured by responses to the question ‘‘Do any of your siblings (brother or sister) smoke cigarettes once a month or more?’’ Responses were dichotomized with a 1 indicating having a sibling who smokes. The two smoking outcomes in high school were respectively dichotomized with a 1 indicating lifetime smoking and cigarette smoking in the past 30 days. Analysis for Smoking Influences in High School Given the variety of schools enrolled, adolescents attending the same schools may have shared similar characteristics relative to those who did not. However, appropriate diagnostics revealed that intraclass correlation (ICC) was negligible in this study. For example, the ICCs were 1.88 9 10-20 and 0.0012365 for lifetime and past-month smoking respectively. Logistic regression first assessed the associations between predictors in high school and lifetime smoking and cigarette smoking in the past 30 days in high school. These two models included the cultural and social predictors of smoking while controlling for gender and age. Quantities of interest were calculated using the estimates from the multivariable analysis by simulation using 1,000 randomly drawn sets of estimates from a sampling distribution with mean equal to the maximum likelihood point estimates and variance equal to the variance covariance matrix of the estimates, with covariates held at their mean values [18]. All tests presented were two-tailed p \ .05. Analysis for Smoking Influences in Emerging Adulthood reported lifetime cigarette use while 9 % reported cigarette use in the past 30 days (Table 1). Participants who reported having an adult who smoked, perceived approval from friends for smoking, or had a sibling who smoked had higher probabilities of lifetime smoking and past-month smoking (Fig. 1). For example, respondents who reported having an adult who smoked were 3 % [95 % confidence interval (CI) 0–6] more likely to report past-month smoking compared with those who did not have an adult who smoked. Participants who reported having a sibling who smoked were 6 % (95 % CI 2–11) more likely to report past-month smoking compared with those who did not have a sibling who smoked. Similarly, participants who perceived approval from friends for smoking were 12 % (95 % CI 5–21) more likely to report past-month smoking compared to those who did not perceive approval. Participants who perceived smoking as more common were more likely to report lifetime smoking as well as pastmonth smoking (Fig. 2). For example, the probability of Table 1 Sample characteristics Mean 95 % CI N Age 15.99 15.98, 16.01 1,688 Male 0.44 0.42, 0.47 1,684 Lifetime smoking 0.38 0.36, 0.40 1,687 Past-month smoking 0.09 0.08, 0.10 1,688 21.14 21.12, 21.16 1,384 0.41 0.21 0.38, 0.44 0.19, 0.233 1,386 1,381 High school Emerging adulthood Age Male Past-month smoking Numbers in cells are means, associated 95 % confidence intervals, and useful sample size for each concept To control for smoking status in high school, this study employed an order one transition logistic model in analysis [19], which took into account the correlation between smoking status in high school (time 1) and emerging adulthood (time 2) while concomitantly assessing the associations between all predictors in high school (considered lagged covariates) and cigarette smoking in the past 30 days in emerging adulthood. Smoking in the past 30 days was the sole outcome in emerging adulthood. Results In high school, 44 % of participants were male, the average age was 16 years and 86 % reported being born in the United States. Among participants in high school, 38 % Fig. 1 The mean effect of each influence on adolescent lifetime and past-month smoking holding covariates at their mean values. Black bars represent 95 % confidence intervals based on 1,000 simulations 123 J Immigrant Minority Health Discussion Fig. 2 The difference in predicted probabilities of lifetime smoking, and past-month smoking, when the 10th and 90th percentile scores are included in computations holding covariates at their mean values. The difference represents the effect of differences in each measure on lifetime smoking, and past-month smoking, given the empirical estimates of the logistic regression. An overlapping confidence interval with zero indicates a null result with alpha = 0.05 past-month smoking among participants who believed 10 % of their peers smoked was about 4 % (95 % CI 3–6) versus 9 % (95 % CI 7–12) among those who believed 80 % of their peers smoked. Participants who held more fatalistic beliefs were more likely to report lifetime smoking as well as past-month smoking. For example, a difference in score on the fatalism measure between the 10th percentile and the 90th percentile was associated with a 4 % (95 % CI 0–7) difference in probability of pastmonth smoking. Participants who perceived more discrimination were also more likely to report lifetime smoking and past-month smoking. For example, a difference in score on the discrimination measure between the 10th percentile and the 90th percentile was associated with a 4 % (95 % CI 1–7) difference in the probability of pastmonth smoking. Parent–child Hispanic acculturation discrepancy was not statistically significantly associated with lifetime smoking or past-month smoking. Smoking in Emerging Adulthood In emerging adulthood, about 41 % of participants were male, the average age was 21 years and 21 % reporting past-month smoking. The associations between all predictors and smoking dissipated by emerging adulthood with p \ .05. On the other hand, past-month smoking in high school was associated with past-month smoking in emerging adulthood. For example, those who reported smoking in high school were 35 % (95 % CI 22–50) more likely to report smoking in emerging adulthood compared to those who did not report smoking in high school. 123 The present study showed that cultural and social influences for smoking among Hispanic adolescents in Southern California dissipate by emerging adulthood. Influences in adolescence could dissipate because more proximal risk and protective factors emerge. These proximal factors might include transition-to-adulthood themes, such as feeling that emerging adulthood is a time of uncertainty or a time for exploration [20]. Specific role transitions [21], such as entering new relationships or loss of employment may also influence smoking behavior [22]. The results from the present study suggest that prevention programs for emerging adults should explore the proximal influences that occur during this phase of the lifecourse rather than rely on previously known predictors of adolescent smoking. Implications for Smoking Prevention in Adolescence Normative influences were associated with smoking among Hispanic adolescents and should be addressed to prevent initiation among this target group. Smoking experimentation and subsequent use develops in a social context; thus de-normalizing smoking is important to prevent initiation and habituation [23]. Research suggested increasing the social unacceptability of smoking would subsequently reduce consumption independently of cigarette tax increases [24]. Local tobacco control policies also influence residents’ perceptions of social norms, with individuals residing in towns with strong tobacco regulations perceiving norms to be more antismoking than those living in towns with less tobacco regulation [25]. Banning smoking in public places in local areas where Hispanics are highly concentrated could prove fruitful in reducing cigarette initiation and continued use [26]. Hispanic youth may act as information leaders for their local communities, fostering the necessary civic engagement to bring about such policy changes [27]. Environmental approaches in prevention have been determined to be more cost-effective than clinical interventions [28], and may prove especially beneficial among adolescents and emerging adults, as they are difficult to engage in traditional smoking programs [29]. School prevention programs can reinforce environmental approaches by denormalizing smoking before initiation occurs or habituation is established [30]. Sibling and adult smoking status were strong influences on individual smoking therefore focusing on ways to combat these influences by de-normalization could prove beneficial. In the case of sibling smoking this could have a transitive effect that extends to the sibling of the individual thus increasing the impact of the intervention. Interventions should also incorporate cultural traits when targeting Hispanic adolescents. Redirecting fatalistic beliefs J Immigrant Minority Health about one’s health being predetermined may prove difficult and should be approached delicately. Teaching positive coping skills among Hispanic adolescents may help reduce the impact of perceived discrimination potentially leading some to smoke. Implications for Smoking Prevention in Emerging Adulthood Similar to other longitudinal studies among adolescents [31–33], this study found smoking in high school was predictive of smoking in emerging adulthood, suggesting smoking experimentation grows into habituation by emerging adulthood among Hispanics. In other words, smoking in emerging adulthood may be due to addiction rendering cultural and social influences negligible factors. Influences of adolescent smoking may also dissipate for an array of other reasons. For example, immediate perceptions of approval of smoking, and the prevalence of smoking, may supersede previous perceptions established in adolescence. Parental or sibling influences may dissipate by emerging adulthood because emerging adults generally live outside of the home with reduced social contact with parents and/or siblings. Alternatively emerging adults may be asserting their independence and parental influence could be less important as it relates to decisions about smoking. Emerging adults also have more opportunities to smoke e.g., reached legal age and acquired an income to buy cigarettes compared to adolescents. In this case, the ability/ opportunity to smoke may be a relatively stronger factor in one’s decision to smoke compared to social or cultural influences. Emerging adulthood is also a time of transition and in some cases difficult transitions may influence individuals to look for ways to cope, triggering smoking initiation. In any case, the present study provided strong evidence that smoking influences are dynamic among Hispanics as they move through the lifecourse and interventions focused on reducing or preventing cigarette use require modifications based on phase of the lifecourse. Limitations of this study include dichotomous outcomes preventing the understanding of smoking quantities. Smoking behaviors were also not validated but relied on self-report. The present study did not employ an exhaustive list of cultural and social influences on smoking due to data limitations. Future studies employing separate predictors may find disparate results lending to the possibility that other smoking influences in adolescence persist into emerging adulthood. While the present study showed having a smoking adult influenced smoking, it could not discern if that adult was prompting the adolescent, served as a smoking model or simply provided easy access to cigarettes. Additionally, the present study could not discern if the adult in the adolescent’s life may have also been his or her sibling. The present study could not show if participants with smoking siblings started smoking prior to their sibling. This study was also limited to adolescents and emerging adults of Hispanic descent and may not generalize to other ethnic groups. In contrast to previous research [4], this study did not find an association between parent–child acculturation discrepancy and smoking. This was likely due to loss to follow-up. Prevention scientists should next attempt to identify the influences among Hispanic emerging adults that weigh on their decisions to smoke during this stage of the lifecourse. Future research should explore how other possible, or known, influences of adolescent smoking persist or dissipate by emerging adulthood. Researchers should examine how social and cultural influences affect smoking quantities and cessation attempts among Hispanics and whether or not these influences change between adolescence and emerging adulthood. These understandings may prove crucial if tailored prevention programs are to be developed that lead to a reduction in the smoking prevalence among Hispanic adolescents and emerging adults. Acknowledgments National Institute on Drug Abuse (Grant # 5R01DA016310-09) and the National Cancer Institute of the National Institutes of Health (Grant # T32CA009492) provided funding for this study. The National Institute on Drug Abuse and the National Cancer Institute of the National Institutes of Health had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. References 1. US Department of Health and Human Services. Preventing tobacco use among youth and young adults: a report of the Surgeon General. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2012. 2. Substance Abuse and Mental Health Services Administration. 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