6 reserch

Health Promotion Practice September 2013 Vol. 14, Suppl 1, 40S –47S DOI: 10.1177/1524839913484762 © 2013 Society for Public Health Education

40S

There is growing interest in understanding individual and environmental influences on youth risk behaviors, including tobacco use. The purpose of this article is to describe the processes and findings from a study that sought to increase the capacity of Asian American and Pacific Islander (AAPI) community-based organiza- tions to understand and address the environmental influences on tobacco use among AAPI youth. Using a multimethod approach to data collection that included GIS (geographic information system) mapping, Photovoice, and individual youth surveys, a team of community and university researchers conducted a 3-year study to assess and address the environmental influences of tobacco use among youth. Community- based participatory research principles guided the study and facilitated unique capacity building and analyses throughout the study period. Results in Long Beach from all three methods highlighted the associa- tions between youth smoking and environmental fac- tors: GIS mapping identified at least 77 separate locations of pro-tobacco influences, photographs cap- tured many of these locations and provided youth lead- ers with opportunities to identify how other influences contributed to smoking risk, and surveys of youth indi- cated that perceived community safety and proximity to pro-tobacco influences were associated with smok- ing in the past 30 days. Subsequent community-based organization activities undertaken by study partners are also discussed, and lessons learned summarized.

Keywords: advocacy; Asian; minority health; com- munity-based participatory research; health research; Pacific Islander; tobacco prevention and control

484762HPPXXX10.1177/1524839913484762H ealth Promotion Practice / MonthTanjasiri et al. / Short Title 2013

1California State University, Fullerton, Fullerton, CA, USA 2Asian Pacific Partnership for Empowerment, Advocacy and Leadership (APPEAL), Oakland, CA, USA 3University of Michigan, Ann Arbor, MI, USA 4St. Mary’s Medical Center, Long Beach, CA, USA

Environmental Influences on Tobacco Use Among Asian American and Pacific Islander Youth

Sora Park Tanjasiri, DrPH, MPH1

Rod Lew, MPH2

Michele Mouttapa, PhD1

Rob Lipton, PhD3

Lillian Lew, MEd, RD4

Sovanna Has4

Michelle Wong, MPH

Authors’ Note: We thank all of the community adult and youth staff from Asian Pacific Psychological Services; Families in Good Health/St. Mary’s Medical Center, Guam Communications Network, Inc.; the Orange County Asian Pacific Islander Community Alliance; and the Washington Asian/Pacific Islander Families Against Substance Abuse. In addition, we want to recognize the special contributions of the following study team members to this article: Ladine Chan, Lisa Fu, Darrah Goo Kuratani, Chork Nim, and Roger Sur. Last, we are grateful to all the adult and youth study participants who participated in the key informant interviews and/or completed individual surveys. This project was supported by the California Tobacco-Related Disease Research Program (Grant Nos. 13AT-3000 and 13AT- 3001, part of which paid for a percentage of Sora Park Tanjasiri’s salary to work on this study), with additional support from the National Cancer Institute’s Center to Reduce Cancer Health Disparities (Grant No. CA 5U54153458). Address correspondence to Sora Park Tanjasiri, California State University, Fullerton, Department of Health Science, 800 N. State College Boulevard, Fullerton, CA 92834-3599, USA; e-mail: [email protected].

Supplement Note: This article is published in the supplement “Promising Practices to Eliminate Tobacco Disparities Among Asian American, Native Hawaiian and Pacific Islander Communi- ties,” which was supported by the Asian Pacific Partners for Empowerment, Advocacy and Leadership (APPEAL) through CDC Cooperative Agreement 5U58DP001520.

Tanjasiri et al. / EnVIROnMEnTaL InfLuEncES On TObaccO uSE 41S

>IntroductIon

Despites decades of aggressive educational and advo- cacy efforts in the united States, tobacco use remains high among american adolescents and young adults, with one in five being daily cigarette smokers at age 18 (Johnson, O’Malley, bachman, & Schulenberg, 2009). available data on asian american and Pacific Islander (aaPI) youth point to similarly high rates of use. for instance, smoking prevalence in californian and Hawaiian ninth graders was 12.1% among filipinos and 19.7% among Pacific Islander ninth graders com- pared with 16.3% among Whites (Wong, Klingle, & Price, 2004). Such data may not be surprising since tobacco use is highly ingrained in the culture of asian countries, where smoking rates are high (e.g., over 40% of men in East and Southeast asia) in large part because it is considered socially and culturally acceptable (banta et al., 2012; Yel, bui, Job, Knutsen, & Singh, 2011). because of gender norms, tobacco use prevalence among aaPI adult men is among the highest in this country: (e.g., 48% to 72% among Laotian, 24% to 71% among cambodian, and 42% among native Hawaiian males; friis et al., 2012; Lew & Tanjasiri, 2003).

Effective youth tobacco prevention must consider the environmental context in which youth live. access to tobacco products, commercial images through local advertising, as well as movie images all may influence youth decisions to smoke (cummings & coogan, 1992; Difranza, norwood, Garner, & Tye, 1987; Lipton, banerjee, Levy, Manzanilla, & cochrane, 2008). In addi- tion, research has shown aaPIs to be at high risk for such environmental exposures. for instance, research- ers studying tobacco industry marketing found that tobacco advertising (including billboards and store- front displays) are more prevalent in ethnically diverse and low-income communities compared with White, affluent ones (Laws, Whitman, bowser, & Krech, 2002; Wildley et al., 1992). In another study of tobacco indus- try documents, aaPI youth were targeted with free cigarette giveaways and other promotion campaigns (Muggli, Pollay, Lew, & Joseph, 2002). Interestingly, perceived community social cohesion and living in an ethnic enclave were found to be important protective factors against youth smoking in aaPI neighborhoods (Kandula, Wen, Jacobs, & Lauderdale, 2009).

The purpose of this article is to describe the pro- cesses and findings from a study that sought to increase the capacity of youth within aaPI community-based organizations (cbOs) to assess and address the envi- ronmental influences on tobacco use in their commu- nities. This effort helped identify important tobacco prevention needs and contribute to youth and cbO

efforts to develop and implement education programs and advocacy efforts.

>MetHod

This was a 3-year (2005-2008) descriptive study of the perceived individual and environmental influences on tobacco use among aaPI youth aged 15 to 25 years. The goals were (a) to design and test the feasibility of environmentally-oriented data collection methods to understand tobacco use influences on aaPI youth and (b) to use a community-based participatory research (cbPR) approach that promotes capacity building in each community to not only understand but also develop policy advocacy-oriented actions to address the environ- mental influences in their lives. four cbOs in california and Washington were approached during the study design phase, due to their previous involvement in a national aaPI tobacco control network through which they had expressed their interests in better understand- ing and addressing issues facing their cambodian, chamorro, Laotian, and multi-aaPI communities. Once the study was funded, the research partnership incorpo- rated core principles of cbPR in all phases of the study design, implementation, and evaluation (Israel, Schulz, Parker, & becker, 1998; Tanjasiri, Kagawa Singer, nguyen, & foo, 2002): shared principal investigators representing both cbO and university researchers, monthly confer- ence calls with the community and university investiga- tors, and biannual in-person daylong meetings with the entire study team during which assessment approaches and instruments were drafted and finalized. cbO staff selected youth who served in leadership positions within their agencies to participate in the design and implementation of the study. Trainings on recruitment and data collection procedures, as well as on public speaking and advocacy planning, were provided at these meetings by university researchers to address needs and requests by the cbO adults and youth leaders. all study protocols, instruments, and consent forms that involved data collection by youth and adults were submitted and approved by the university institutional review board. all cbOs received monetary support from the grant for their involvement.

Data Collection Methods

Our community-informed assessment of environ- mental influences on aaPI youth smoking was informed by three mixed-method data collection strate- gies: geographic information system (GIS) mapping, Photovoice, and individual youth surveys.

42S HEaLTH PROMOTIOn PRacTIcE / September 2013

GIS mapping. GIS mapping involves the collection of geo-coded data to locate sites of interest on maps and has been used to show the correlation between per- ceived access and objective access in studies of healthy environments (caspi, Kawachi, Subramanian, adam- kiewicz, & Sorensen, 2012; Moore, Diez Roux, & brines, 2008). In this study, we used global positioning system (GPS) devices to collect and store location data (called “waypoints,” which are exact longitude and latitude coordinates) on community locations of particular inter- est. Through discussions at biannual in-person meet- ings, our study community partners were most interested in identifying the locations of items (e.g., tobacco adver- tisement) or activities (e.g., hangouts where youth smoked together) that promoted smoking as an appeal- ing behavior for youth. furthermore, cbO adult staff were also interested in identifying those places (e.g., community centers) where healthy behaviors were pro- moted that could help protect youth from smoking. next, key informant interviews with 36 youth and com- munity leaders (e.g., social service agency staff, minis- ters, and elders) were conducted to (a) understand the physical boundaries of the ethnic community, (b) iden- tify the kinds of locations they perceived as having pro- tobacco (our term for locations that promoted smoking) influences on youth, and (c) identify the kinds of loca- tions that they perceived as having anti-tobacco (our term for locations that promoted healthy behaviors other than smoking) influences on youth. In Year 1, key informant interview trainings were conducted by cbO adult staff and youth leaders to discuss informed con- sent, informant selection, and interview processes. Each interview lasted approximately 1 hour, and after com- pletion cbO adult staff and youth leaders wrote sum- maries of the interviews based on written notes and tape recordings.

Summaries from key informant interviews were shared with all study team members, who then devel- oped a list of all types of community influences on youth tobacco use. Each item on this list was assigned a waypoint code number and categorized as a pro- tobacco or anti-tobacco influence. In Year 2, GPS devices (Garmin eTrex) were purchased from a local sporting goods store and programmed with the way- point code numbers. for approximately a 2-month period, pairs of cbO adult staff and youth leaders walked through the entire community (using bounda- ries defined via key informant interviews) and inputted the waypoints (n = 111 total) by perceived category (pro-tobacco or anti-tobacco) into their GPS devices. for each waypoint, youth also used written log forms to provide brief descriptions of each location.

Photovoice. Photovoice is a process that promotes com- munity empowerment by engaging people in identify- ing the needs of their own communities through photography by using the photographs as the focal point of group discussions about why these needs exist and sharing the photographs with policy makers in order to create positive community changes (Wang & burris, 1997). During GIS data collection in Year 2, a total of 32 youth leaders also took pictures of any com- munity location that they believed influenced youth toward tobacco use. Photographs were uploaded onto the cbO computer and displayed for the youth, at which time the youth selected specific photographs that appealed to them. The youth then used the Photo- voice “SHOWeD” mnemonic to develop written analy- ses of each picture that described what they saw, why they believed the situation existed, and what they rec- ommended to address the situation (Wang & burris, 1997). a more in-depth description our Photovoice methodology and results are presented in a previous publication (Tanjasiri, Lew, Kuratani, Wong, & fu, 2011).

Youth surveys. Due to a limitation in funding, a self- administered survey of youth was undertaken only in Long beach to quantitatively explore the relative influ- ences of interpersonal and community factors on youth smoking. The survey included standard items from the national Health Interview Surveys and california Tobacco Surveys on the use of tobacco and other drugs, as well as demographics and ethnic identity (Pierce et al., 1998; Pierce, fiore, novotny, Hatziandreu, & Davis, 1989). In addition, items were also included on commu- nity safety and violence, youth access to tobacco and other drugs, and youth participation in leadership and/ or other protective programs in their communities. This subjective assessment of a youth’s neighborhood pro- vides some insight into environment/neighborhood stressors and mitigators of stress that might bear on tobacco use. at the end of Year 1, the survey was pilot- tested with 12 youth to confirm comprehension and time duration, and was then implemented in Year 2. a total of 10 youth leaders at each cbO were trained on identifying and recruiting youth respondents (from shopping malls and other youth hangouts), consent pro- cedures, and administering the surveys. at the conclu- sion of each completed survey, youth respondents were given two movie tickets valued at approximately $15. by the end of Year 2, a total of 298 surveys were com- pleted by cambodian youth 15 to 25 years old. a total of 33 youth who were approached refused to participate (for an overall response rate of 90%) with reasons for

Tanjasiri et al. / EnVIROnMEnTaL InfLuEncES On TObaccO uSE 43S

refusal including the lengthiness of the survey and dis- interest in the incentive items.

Data Collection, Management, and Analyses

Due to the multiple data activities and unique cbO efforts in each geography area, the remainder of this article will focus on describing the processes in Long beach, california. Data collection proceeded over approximately 8 months in Year 2, during which time GPS and Photovoice data were conducted, and indi- vidual surveys were collected in Long beach. because youth were interested in seeing a different city environ- ment, they also went to Pasadena, california, and con- ducted Photovoice. Throughout this time, cbO staff coordinated the transfer of GPS data and log forms, photographs with SHOWeD analyses, and individual surveys to the university study team members for data input and analyses. Geo-coded data was downloaded from the GPS devices and coded as either a pro-tobacco or an anti-tobacco community influence on youth tobacco use. Photos were stored as image files on cDs, whereas any text-based data were maintained in elec- tronic word-processing files. all of the photos were reviewed and coded for themes reflective of the con- cerns raised by the SHOWeD analyses.

all individual survey data were entered using SPSS Version 16. Outcome variables for this study were ever smoking and smoking within the past 30 days, whereas predictor variables included a six-item scale that assessed negative attitudes toward smoking (e.g., I dis- like being around people who are smoking), number of similar-aged peers they know who smoke cigarettes or use other tobacco products, perceived level of safety and perceived level of stress in the neighborhood they live in, and having ever participated in a community youth program where they live (yes or no). In Year 3, descriptive statistics were calculated for the variables listed above, as well as for the demographic variables of age, ethnicity, gender, grade in school, born in the united States (yes or no), and the approximate amount of discretionary money that participants have per week to spend on themselves. Two multiple logistic regression models were calculated: one predicting smoking 100 cigarettes and one for past 30 day smok- ing. These models included only predictor variables and demographic variables mentioned that were sig- nificantly associated with the outcome variable in bivariate analyses. Last, survey and GIS data were also analyzed in Year 3 to determine associations between smoking and proximity to pro- or anti-tobacco influ- ences in the community. average distance (in miles)

between home address (obtained from individual sur- veys) and positive influence locations for smoking (collected by GPS devices) were calculated and then entered as a predictor variable in a logistic regression with the outcome smoking in the past 30 days (yes or no) and ever having smoked 100 cigarettes for one’s whole life (yes or no).

>results

as shown in Table 1, the overwhelming majority (n = 74) of waypoints in Long beach were categorized as pro-tobacco because youth leaders perceived these locations as promoting smoking as appealing to youth. These pro-tobacco locations included tobacco adver- tisement, convenience shops, fast-food restaurants, residences, schools, community spaces, faith institu- tions, and bus stops. Many locations (n = 27) were perceived by youth leaders to be both anti- and pro- tobacco, such as one middle school (that was per- ceived to fight smoking through anti-tobacco education but that also had areas on campus where youth com- monly smoked) and one church (where healthy com- munity values were promoted but also where smokers congregated and left their butts on the sidewalk). Only 10 locations were perceived by the youth leaders to be anti-tobacco influences, including three liquor stores (that did not promote tobacco sales), the community recreational center, and a high school (both of which strictly enforced no-smoking policies).

Spatial analyses found associations between prox- imity to pro-tobacco influences and youth smoking behavior. as shown in Table 2, youth who smoked within the past 30 days lived significantly closer in proximity to negative influences compared with youth who did not smoke in the past 30 days. Youth who smoked at least 100 cigarettes in their lifetime, how- ever, did not appear to live any closer in proximity to negative influences, perhaps indicating that such sites did not influence maintenance as much as initiation. Last, youth who were involved in leadership programs (e.g., at their schools, at cbOs, etc.) lived significantly farther away from negative influences than youth who did not participate in such programs.

Photographs and descriptions developed by the youth exemplified four different kinds of environmen- tal factors on smoking: (a) youth-targeted cigarette advertisements, (b) the abundance of smoke shops dis- playing cigarette advertisements of any kind, (c) the poor physical appearance of their community, and (d) anger at tobacco companies that were profiting from

44S HEaLTH PROMOTIOn PRacTIcE / September 2013

their community. One youth took a picture of a tobacco outlet (figure 1) and described it as promoting youth smoking via youth-targeted advertisements and sales by stating,

a smoke shop is on PcH (Pacific coast Highway), so when people drive by they can see the smoke shop. There are a lot of advertisements on the window and it is near an elementary school. To stop kids from using drugs, we need to start a program to tell the teens about the consequence of drugs. Someone can buy the store and make the smoke shop move.

as shown in figure 2, another youth selected and described a photograph depicting the poor physical quality of the city as part of the reason why youth also smoke. according to this youth,

Driving by the ditch, people can see all the graffiti and all the litter. The graffiti is in a neighborhood and it’s gang related. all the litter and graffiti make Long beach look bad. We should make a place, so they can tag and start a gang prevention program.

In contrast, when they went to Pasadena the youth were struck by the lack of cigarette and other promo- tions, as well as the general cleanliness and beauty of the city environment. In describing figure 3, one youth wrote,

table 1 types of Pro- and anti-tobacco locations Influencing

Youth smoking in long beach

Anti- Tobacco

Pro- Tobacco

Both Pro and Anti

ads cigarette ad 4 Shops Liquor store 3 10 2 Smoke shop — 4 — Gas station — 1 2 Small market — 5 2 Supermarket — 2 — Other 1 2 2 food fast food 1 1 2 Donut shop — 2 — Restaurant — — 1 coffee shop 1 — — Residential House 1 7 — apartment — 2 — Schools Elementary — 2 — Middle — — 2 High 1 1 1 community Park — 6 4 Recreation

center 1 — 3

Library — 1 — faith church — — 1 Temple — — 1 Transportation bus stop — 2 2 Parking lot — 4 1 Health clinic — 1 — Hospital 1 — — Other alley — 9 — Ditch — 5 — Sidewalk — 3 — Laundromat 1 — — Total 10 74 27

table 2 associations between Proximity (in Miles) to Pro-

tobacco Influences and Youth smoking in long beach

Variable Proximity to Pro-

Tobacco Influences p

Smoked in last 30 days Yes 1.49 * no 2.06 Smoked 100+ cigarettes

in lifetime

Yes 1.97 ns no 1.98 Participated in leader-

ship programs

Yes 2.26 * no 1.70

*p < .05

Tanjasiri et al. / EnVIROnMEnTaL InfLuEncES On TObaccO uSE 45S

This picture shows how clean Pasadena is and the environment around it. Pasadena is a clean place and isn’t as dirty as Long beach. . . . not a lot of people smoke in Pasadena and there is barely any cigarette ads around. after looking at this picture and how clean it is I want Long beach to be the same, to be clean, pretty, and a great place.

Last, youth surveys indicated that perceptions of the environment were associated with smoking status. Of the 298 youth who participated in the survey, 93.6% were all or part cambodian, 52.9% were male, and 83.2% were between 16 and 19 years old. The majority were born in the united States (92.7%), were 11th or 12th graders (71.7%), and had more than $10 of discretionary spending money per week (68.9%; data not shown). cronbach’s alpha was .83 for the positive attitudes toward smoking scale; with possible

scores ranging from 0 to 18, the mean score was 5.8 (SD = 4.1). nearly all participants (90.2%) indicated that at least “a few” of the same-aged peers whom they knew smoked cigarettes or other tobacco products. close to 1 in 4 participants indicated that their neigh- borhoods were either “unsafe” or “very unsafe” to live in (25.3%) and either “stressful” or “very stressful” to live in (22.9%). nearly half (49.3%) had ever partici- pated in a youth program within their community. Of the entire sample of 298 participants, 138 (46.3%) indicated that they had ever tried smoking, and 61 (20.5%) indicated that they smoked at least one ciga- rette in the past 30 days (data not shown).

Table 3 presents multiple logistic regression results of the two outcome variables: smoking 100 cigarettes in lifetime and smoking in past 30 days. Smoking 100 cigarettes in lifetime was positively associated with positive attitudes toward smoking. Past 30-day smok- ing was associated with positive attitudes toward smoking and perceived neighborhood safety and was marginally associated with the number of known peers who smoke. although preliminary bivariate analyses indicated that males had higher rates of lifetime smok- ing, that discretionary income was positively associ- ated with past 3-day smoking, and lifetime participation in a youth program within their community was nega- tively associated with past 30-day smoking, none of these associations were significant in the multivariate analyses.

>dIscussIon

We found that perceived environmental factors/ features had a substantial influence on aaPI youth smoking risk and behaviors. Data from all three mixed- methods (survey, Photovoice, and GIS mapping) identified

FIgure 1 smoke shop in long beach

FIgure 2 community conditions in long beach

FIgure 3 environmental condition in Pasadena

46S HEaLTH PROMOTIOn PRacTIcE / September 2013

the many and diverse environmentally oriented influ- ences on youth smoking, including not only tobacco- related factors (e.g., cigarette advertisements) but also community-related factors (e.g., perceived safety of the community, which was slightly more predictive of 30-day smoking than number of smoking peers) that put youth at risk for using tobacco products.

Perhaps more important, youth were empowered to use the study results to postively influence their envi- ronment. When the youth in Long beach compiled their Photovoice and GIS mapping results in Year 3, they were motivated to share the findings with local stakeholders. The youth created a display that was pre- sented to the coalition for a Smoke free Long beach, which was working on a tobacco retailer permit (TRP) ordinance. The coalition arranged for the youth to pre- sent to the city councilperson of the sixth district, with the message that there were too many smoke shops and liquor stores selling cigarettes in their community. In the words of one youth leader, “Though I know that tobacco alone can be harmful . . . but growing up and living in the ghetto part [of] Long beach is also danger- ous. I’ll probably die from gang violence before dying from cancer.” One month later, that city councilperson put the TRP on the city council agenda where it was unanimously passed, and the youth leaders were cred- ited with helping the council recognize the importance of promoting citywide policies for positive community change.

although many positive processes and outcomes arose from this study, we also faced many challenges

that limit the generalizability and replicability of our efforts for other communities and populations. Given the focus on youth empowerment, nonprobability sam- pling based on youth organizational affiliation was used throughout all data collection efforts. Thus, results many not be applicable to the larger chamorro, cambodian, and Laotian communities. Since the sur- vey was only administered to cambodian youth in Long beach, we are uncertain about the applicability of results to the other aaPI subgroups. Given the explora- tory nature of the study, we did not measure the valid- ity or reliability of the scales and coding methods. Last, we did not measure the impacts of the cbPR-informed trainings on changes in individual knowledge and skills. Despite these challenges, however, partnering cbO and university institutions emerged from this pro- cess with greater understanding of and capacities to address larger community-level influences on aaPI youth tobacco use.

Lessons Learned

ultimately, we hope this article describes how inno- vative, mixed-methods approaches can not only provide critical community assessment information to plan future interventions but also creatively engage youth and community members in tobacco control. from our experience, we also found that GIS and Photovoice yielded visually powerful information that could be used to facilitate discussions of environmentally ori- ented community recommendations. To the degree that

table 3 logistic regression of self-reported 100-cigarette and Past 30-day smoking (n = 298)

Smoked 100 Cigarettes During Lifetime

Smoked in Past 30 Days

Odds Ratio p

Adjusted Odds Ratio p

Predictor variables Positive attitudes toward smoking 1.21 ** 1.47 *** number of known peers who smoke — — 1.46 ns Perceived neighborhood safety (not safe) — — 1.88 ** Demographic variables Gender (female) — — 1.03 ns Discretionary money per week — — 1.08 ns

**p < .01. ***p < .0001.

Tanjasiri et al. / EnVIROnMEnTaL InfLuEncES On TObaccO uSE 47S

these assessments and recommendations are shared with policy makers, they become advocacy tools that can con- tribute to community-wide tobacco policy change.

furthermore, we credit the cbPR approach as essen- tial in our efforts to develop innovative and commu- nity-responsive research strategies and engagement mechanisms. cbPR efforts such as daylong biannual meetings that included trainings on research knowledge and advocacy skills helped promote community readi- ness to support policy opportunities as they arose, such as Long beach’s TRP ordinance. close collaborations between university researchers and cbO staff informed the design, development, testing, implementation, anal- ysis, and dissemination of all GIS and Photovoice activities in our aaPI communities. We strongly feel that cbPR should be a key strategy for populations that have not been effectively reached for tobacco preven- tion and control, and hope that future research builds on our efforts to take a community-informed approach in assessing and addressing the many environmental influences on youth tobacco smoking.

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