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ORIGINAL RESEARCH

Smoking in young adult African Americans

Pamela R. Jones, Marlene Z. Cohen, Helen E. McIlvain, Mohammad Siahpush, Alexis Scott &

Kingsley Okafor

Accepted for publication 7 September 2013

Correspondence to P.R. Jones:

e-mail: [email protected]

Pamela R. Jones MPH PhD RN

Clinical Supervisor

Capital Caring, Washington, District of

Columbia, USA

Marlene Z. Cohen PhD RN FAAN

Professor and Kenneth E. Morehead

Endowed Chair in Nursing, Associate Dean

for Research

College of Nursing, University of Nebraska

Medical Center, Omaha, Nebraska, USA

Helen E. McIlvain PhD

Professor

Department of Family Medicine, University

of Nebraska Medical Center, Omaha,

Nebraska, USA

Mohammad Siahpush PhD

Professor

College of Public Health, University of

Nebraska Medical Center, Omaha,

Nebraska, USA

Alexis Scott RN

Registered Nurse

College of Nursing, University of Nebraska

Medical Center, Omaha, Nebraska, USA

Kingsley Okafor MD

Physician

College of Medicine, University of Nebraska

Medical Center, Omaha, Nebraska, USA

J O N E S P . R . , C O H E N M . Z . , M C I L V A I N H . E . , S I A H P U S H M . , S C O T T A . &

O K A F O R K . ( 2 0 1 4 ) Smoking in young adult African Americans. Journal of

Advanced Nursing 70(5), 1117–1127. doi: 10.1111/jan.12272

Abstract Aim. The aim of this study was to describe factors that influence decisions of

young African Americans to start smoking.

Background. Young adult African Americans have a high risk for becoming

regular smokers, but little is understood about their smoking. This knowledge is

needed because understanding young adults’ smokers will help develop effective

tobacco cessation and prevention strategies.

Design. Qualitative study.

Method. The study consisted of 22 in-depth interviews with African Americans

between the ages of 19–25. Data were collected between 2009–2010. Smokers,

former smokers and non-smokers were included.

Results/findings. Results indicated that smoking identity of young adults was

influenced by their limited and discounted knowledge of health risks and the

stigma associated with the type of tobacco smoked. The importance of cost was

discussed as was the effect of smoking on relationships and vice versa. Marijuana

was the primary reason they started smoking tobacco. Their transition into

adulthood and views of smoking, adulthood and success all influenced smoking.

Additionally, self-reflection on personal choices around smoking was important

and may be useful in effective smoking cessation programmes for this group.

Conclusion. Nurses are in an ideal position to promote effective smoking

cessation in young adults. Direct, culturally relevant messages are needed that fit

into the context of the young adults’ lives by addressing concurrent use of

marijuana, self-esteem and success in life.

Keywords: cancer prevention, health disparities, qualitative research, tobacco

use, African Americans, smoking, marijuana

Introduction

Worldwide, 12% of all deaths are associated with

tobacco use (World Health Organization 2012). Cigarette

smoking is the most preventable cause of death in the

USA. Annually, approximately 443,000 people in the USA

die due to smoking or exposure to second-hand smoke

(Centers for Disease Control 2009). In low-income and

middle-income countries, the Global Adult Tobacco Sur-

vey found high rates of smoking in men and early smok-

ing initiation in women (Giovino et al. 2012).

Additionally, daily tobacco use is associated with respira-

tory disease and general malaise (Brook et al. 2004) and

increased mean lung age (Lipkus & Prokhorov 2007) in

young adulthood. The most effective methods of reducing

tobacco-related deaths are preventing smoking initiation

and smoking cessation.

Racial minorities tend to experience higher rates of

tobacco-related health disparities. While Black adult smok-

ers tend to smoke fewer cigarettes per day than White

smokers, they have greater tobacco-related health dispari-

ties (Fagan et al. 2004). Additionally, African American

smokers metabolize nicotine slower than White smokers

(Kandel et al. 2007, Rubinstein et al. 2012) and the rates

of lung cancer in Black adults are higher than the rates of

Whites (American Cancer Society 2011).

The smoking prevalence rate of young adults, aged

18–24 years old in the US is 34.2% (Department of Health

& Human Services, Centers for Disease Control & Preven-

tion, National Center for Chronic Disease Prevention &

Health Promotion, & Office on Smoking & Health 2012),

27% in Great Britain (Office for National Statistics 2012)

and evidence shows a decrease in smoking rates among

young adults (Lawrence et al. 2007). Smoking rates are

associated with the vulnerability of young adults to ciga-

rettes during times of dramatic life transitions in social

networks and living arrangements (Ling & Glantz 2004)

and exposure to media campaigns that normalize smoking

behaviour (Ling et al. 2009). Until recent years, there has

been little research on preventing tobacco use in young

adults as smoking cessation and prevention interventions

have almost exclusively focused on adolescents (Rigotti

et al. 2005). The lack of research on young adults’ smokers

limits the ability to develop effective tobacco cessation and

prevention strategies.

Addressing tobacco use among young adults is important

for several reasons. First, the process of becoming a regular

smoker develops over years with periods of daily and

non-daily smoking (Doubeni et al. 2010). Thus, intervening

in young adulthood may prevent an individual from becom-

ing a regular smoker. Second, while many people start

smoking in adolescence, approximately 20% of people

begin smoking in young adulthood (Hammond 2005).

Third, smokers who quit by the age of 30 avoid much of

the harm associated with tobacco use (Doll et al. 2004).

Finally, young adult smokers are more likely to have tried

to quit smoking than older smokers, but are less likely to

use effective strategies when attempting to quit (Suls et al.

2012).

A smoker’s intention to quit smoking has been associ-

ated with receiving advice from a health professional

to quit smoking (Fiore et al. 2008). As the largest health-

care workforce, nurses have an important role in the

reduction in tobacco-related illness and deaths. Studies

have shown that telehealth programmes conducted by

nurses increased smokers’ motivation to quit smoking

(Battaglia et al. 2013). In hospitals and clinics, nurses are

Why is this research or review needed?

• Approximately 20% of people begin smoking in young

adulthood and smokers who quit by the age of 30 avoid

much of the harm associated with tobacco use.

• Blacks tend to start smoking regularly as young adults and

their smoking behaviours have been associated with social

support, family lives, unemployment and financial strain;

however, little is known about effective smoking cessation

strategies.

What are the three key findings?

• Black young adults have limited understanding of the

health risks of all types of tobacco.

• Tobacco was often smoked with marijuana and marijuana

use often preceded tobacco use.

• Self-reflection had an impact on some participants’

thoughts about quitting smoking.

How should the findings be used to influence policy/ practice/research/education?

• Culturally appropriate tobacco cessation and prevention

efforts for young adult African Americans should focus on

the joint use of marijuana and tobacco use and the health

effects of little cigars.

• Community-based participatory research that includes

young adults and social marketing agencies with demon-

strated experience with this population can have an impor-

tant role in developing and implementing effective

interventions for this vulnerable population.

• Nurses are well positioned to provide education aimed at

reducing risky behaviours, including smoking and to pro-

mote methods for effective smoking cessation.

P.R. Jones et al.

well positioned to provide education aimed at reduc-

ing risky behaviours in acutely ill individuals in emer-

gency rooms, clinics and hospital rooms (Sommers et al.

2013).

Background

In the young adult population, some groups, including

racial minorities, are more vulnerable to becoming addicted

to tobacco and less likely to quit smoking. For example, in

United States, the smoking prevalence of White adolescents

is higher than Black adolescents; however, the prevalence of

smoking in African Americans is higher than the smoking

prevalence of Whites in young adulthood (Kandel et al.

2007). Additionally, African Americans tend to become reg-

ular smokers as young adults, unlike White young adults

who tend to become regular smokers in adolescence (Trini-

dad et al. 2005).

Research on tobacco use in young Black adult has been

primarily epidemiological. Tobacco use among African

Americans has been associated with the sale of single ciga-

rettes (Stillman et al. 2007), social networks (Ellickson

et al. 2004, Morrell et al. 2005), socioeconomic status

(Narula et al. 2012) and positive family lives (Marcus

et al. 2007). Additionally, socioeconomic variables, such

as unemployment (Kendzor et al. 2012) and financial

strain (Kendzor et al. 2010), have been associated with

smoking cessation. A South African study found that girls

who were depressed were more likely to be current smok-

ers (Fernander et al. 2006).

Qualitative studies have found that tobacco use was asso-

ciated with stress and cigar use (Jolly 2008) and that young

Black adult inhale deeper when smoking than their White

counterparts (Peters et al. 2012). The later age of becoming

a regular smoker and the disproportionate tobacco-related

disease burden indicates a need for culturally appropriate

interventions that extend through young adulthood,

particularly among African Americans. Nurses are in an

excellent position to implement these health promotion

interventions. Therefore, the aim of this study was to

describe and understand the attitudes, beliefs and factors

that influence the smoking behaviours of young Black

adult as these views are not well understood.

The study

Aim

The aim of this study was to describe factors that influence

decisions of young Black adult to start smoking.

Design

Because there is a paucity of literature on effective smoking

prevention and cessation interventions for Black young

adults, a qualitative approach was used for this study

(Sandelowski 2000, 2010).

Participants

Participants were recruited with flyers placed in the commu-

nity and by snowball sampling. The flyers requested inter-

views with Blacks between the ages of 19–25 to discuss

smoking. All participants were recruited from a Midwestern

state. Eligible participants were young adult non-Hispanic

Blacks between 19–25 years of age. Participants were asked

to self-identity their race and a definition was not provided.

Because we were interested in both the reasons for smoking

and the reasons for not becoming a smoker, we interviewed

non-smokers, current smokers and former smokers to

understand the meaning of smoking from several perspec-

tives.

Data collection

The study consisted of an individual interview and a second

interview to verify the study results. Interviews were

conducted in a location selected by the participants, for

example, a private home or at the university. All interviews

were conducted by one interviewer. During the first inter-

view, a semi-structured interview guide was used to elicit atti-

tudes and beliefs about tobacco use and ideas about effective

strategies/messages for tobacco prevention and cessation. The

interviewer asked the participants the following questions:

Please tell me about what smoking is like in the Black com-

munity? [This was asked only after the participant identified

themselves as Black.] Please talk about what it means to you

to be a smoker/non-smoker? What experiences have you had

that effect your views on smoking? What type of non-smok-

ing messages would appeal to you?

The second interview was focused on verifying the accu-

racy of the data analysis. Each participant received a $25

gift card at the completion of each interview. Interviews

were conducted until data saturation was reached (that is,

until no new themes were identified), meeting the standard

criterion used in qualitative research (Cohen et al. 2000).

Ethical considerations

Prior to data collection, the university institutional review

board approved the study and each participant provided

JAN: ORIGINAL RESEARCH Smoking in Young Blacks

written informed consent. As the primary researcher was a

Black investigator, a multi-racial research team conducted

the study to ensure that the study results were based in

study data rather than on the Black investigators’ knowl-

edge of the community. Members of the research team were

not also participants in the interviews. The study explored

attitude about tobacco use; however, participants voluntar-

ily discussed the use of addictive substances. Participants

were assured of confidentiality and that the research team

would not disclose any information that would have an

impact on their employability or reputation. Additionally,

the research team was careful not to exploit the partici-

pants. The study themes that focused on marijuana use

were discussed with participants to ensure that they agreed

with the themes and their disclosure in a publication.

Data analysis

The research team comprised two tobacco control research-

ers, a researcher with extensive experience with qualitative

research, a psychologist and two Black young adults who

were not study participants. The research team had meet-

ings during the study to discuss the study design, interview

guides, data collection and analysis.

Each interview was tape-recorded and transcribed verba-

tim. A member of the research team checked the accuracy

of the transcripts with the tape-recorded interview. Each

transcript was read and re-read. A thematic analysis of each

interview was conducted by two of the researchers (Braun

& Clarke 2006). To identify themes, the authors read each

transcript to get a sense of each interview as a whole. They

then examined each transcript line by line and underlined

and labelled passages with tentative theme labels. Passages

from each interview text with the labels, or theme labels,

for each interview were compared with passages and

themes among and between all other interviews. After these

two researchers completed the analysis, the team members

reviewed the thematic labels and passages that illustrated

the themes. The analysis was discussed among the team

members until a consensus was reached.

Rigour

Procedures to ensure scientific rigour included having the

analysis conducted by two researchers and validating the

themes with the other members of the research team and

with participants. All authors of the paper reviewed the

theme labels and passages and consensus was reached. After

completion of the initial analysis, a preliminary draft of the

results was presented to two study participants to validate

the interpretation and ensure accuracy of this interpreta-

tion. Questions were asked to verify the validity and

completeness of the data. The study participants verified

the analysis and interpretation of study results.

Results

Sample

Twenty-two interviews were conducted with non-Hispanic

Blacks between the ages of 19 and 25. All participants self-

identified as Black. Participants identified themselves as

having a varied smoking status: eight were current smokers,

seven were former smokers and seven had never been

smokers. Almost one-third of the participants (n = 6) were

male, most were college students (n = 17) and almost half

(n = 10) had an income less than $10,000.

Themes

Table 1 shows six themes identified from the interviews: 1.

smoking identity, which was influenced by limited and

discounted knowledge of health risks and the stigma of

smoking cigarettes; 2. Importance of Cost; 3. effect of

smoking on relationships and vice versa; 4. The link with

marijuana; 5. smoking, adulthood and success; 6. Self-

reflection: potential tobacco control interventions.

Smoking identity

Smoking status was an important part of the participants’

identity. Non-smokers expressed pride that they were

non-smokers. However, some former and current smokers

did not consider themselves current or former smokers.

Table 1 Factors influencing smoking in young adult African Americans.

A. Smoking Identity

a. Limited and discounted knowledge of health risks.

b. The stigma of smoking cigarettes.

B. Importance of cost

C. Relationships

a. Smoking to be socially acceptable.

b. Smoking identity influences friendships.

c. Dating only non-smokers

D. Link with Marijuana

a. Smoking marijuana first.

b. Boosting their marijuana high.

E. Smoking, adulthood and success

a. Having a life plan

b. Success

F. Self-Reflection: Tobacco Control Interventions

P.R. Jones et al.

One participant stated that she was a social smoker, mean-

ing someone who smoked only in social settings. Because

she believed that smoking was the consistent practice of

using tobacco products, she did not consider herself a smo-

ker. Other participants, who identified themselves as

non-smokers, discussed smoking occasionally. From their

perspective, the label of smoker did not include individuals

who smoked tobacco occasionally:

A smoker is somebody that constantly, consistently, is smoking,

putting something in their lungs. Versus a social smoker is some-

body that might smoke maybe on the weekends or when they’re in

a group, like hookah smokers. [Female]

Some participants believed that being a smoker required

an addiction to tobacco. For one person, being a smoker

was related to the uncontrollable physical and psychological

desire to smoke tobacco. However, when the desire to

smoke tobacco was controlled, she no longer viewed herself

as a smoker:

I think when you start relying on it and there’s an addiction

involved where you have to do it, like specific times of day, specific

moments, you just have to have one. And so that’s why I don’t see

myself as a smoker now. Because when I was in heavily, it was

specific times, specific events, I just had to have one, so I was a

smoker….So that’s why I don’t see myself as a smoker now.

[Female]

Limited and discounted knowledge of health risks

Their identity as a smoker was influenced by their limited

and discounted knowledge of health risks. Many partici-

pants knew that cigarettes contained several harmful chemi-

cals that led them to avoid smoking cigarettes. However,

many smoked Black and Milds, a little cigar, instead of

cigarettes. Most participants believed that Black and Milds

(also referred to as blacks) were stronger than cigarettes.

Several participants noted that blacks are five times stronger

than cigarettes, but they were not sure about the health

risks associated with blacks, or if Black and Milds

contained the same chemicals as cigarettes:

The Black and Milds, they say, are worse than cigarettes. I know it

[cigarettes] contained battery acid, rat poisoning and all that stuff,

which is pretty interesting. I don’t know if…that stuff might be in

Black and Milds….that’s one of the biggest reason why I never

smoked cigarettes, on top of I don’t like the way they smell. But, I

really can’t tell you if that’s the same thing for blacks and if I prob-

ably found that out, I probably wouldn’t smoke them. [Female]

While they knew the health risks of smoking cigarettes,

this knowledge did not influence them to quit smoking. For

those young adults, the lack of knowledge about Black and

Milds and the associated health risks did not cement their

self-identity as a smoker.

The stigma of smoking cigarettes

Their identity as a smoker was also influenced by the

stigma attached to cigarettes. Smokers said that different

types of tobacco were viewed differently. They saw ciga-

rette smoking as having more stigma than Black and Milds

in their social groups. Cigarettes were described as products

usually smoked by older adults and non-minorities:

Cigarettes are lighter than blacks are but I think blacks do the

same effect as far as boosting a high too, so. Yeah. I think those

are more accepted. I think some Black people kind of look down,

like, ‘Ooo, you smoke cigarettes.’ [Female]

I’m more of ashamed that I smoke cigarettes, to be honest….most

of the people that I hang out with, they’re not accepted like that.

You know? It’s just that’s for old people….It would be more

accepted if I lit up a black and, you know, nobody’s going to look

at me funny. [Female]

Importance of cost

Price was also important for these young adult smokers.

Many preferred Black and Milds to cigarettes because they

were less expensive and it was possible to buy just one lit-

tle cigar as opposed to a pack of cigarettes. Even partici-

pants who smoked cigarettes saw Black and Milds as a

cheaper alternative when they had limited finances. How-

ever, cigarette smokers believed that the price of cigarettes

would have to almost double to prompt them to quit

smoking:

They would have to be ten dollars [for me to quit smoking]. I got

them yesterday for like $5.10 which is really, really cheap.

[Female]

Relationships

Smoking to be socially acceptable

Personal relationships were influential for the young adults

when they were making decisions about tobacco use.

Family members were especially influential in young

adults’ decision to smoke. Young adult smokers men-

tioned that they first tried tobacco and/or marijuana with

cousins, siblings and parents. These young adults initiated

tobacco use hoping to establish a closer bond with a fam-

ily member:

JAN: ORIGINAL RESEARCH Smoking in Young Blacks

It was more like a family social thing, getting closer to my cousin,

whatever. And from that point, I did it with pretty much that

cousin, for a while. [Female]

Parents influenced how participants viewed tobacco use,

but had limited impact on their smoking behaviours. Smok-

ers and non-smokers identified that having a parent who

approved or disapproved of smoking shaped their views

about smoking. Many mentioned that their non-smoking

parents did not allow social interaction with smokers

because they did not approve of smoking and were very

religious individuals:

I just completely kept it from them to kind of keep my image

intact….[being a] good girl. I’m not saying that smoking means

you’re a bad person, but just in the eyes of like my grandparents.

[Female]

Most smokers with non-smoking parents strove to hide

their smoking from their non-smoking parents. In contrast,

smokers with smoking parents admitted that they grew up

thinking that smoking tobacco was normal. A participant

discussed how smoking norms led her mother to believe

that her children would become smokers: ‘That’s why my

mom probably made that statement about, ‘You’re proba-

bly going to be a smoker’. Because smoking was the norm.’

[Female]

Smoking identity influences friendships

Participants commented that they tended to have friend-

ships consistent with their smoking status. Non-smokers

tended to have more non-smoking friends and smokers had

more smoking friends. Former smokers talked about estab-

lishing new friendships with non-smokers once they made

the decision to quit smoking:

I’m around people who are like me. So, if you don’t smoke, I’m

more likely to be around you than if you were someone who was a

smoker. [Female]

Some participants who smoked indicated that they appre-

ciated spending one-on-one time with non-smoking friends.

Out of respect, the young adults frequently tried not to

smoke around non-smoking friends. Participants

commented that when smokers gathered socially that every-

one was expected to smoke cigarettes or Black and Milds.

For some participants, time spent with non-smokers was a

way to reduce the amount of tobacco smoked.

Some women started smoking tobacco to change their

image; however, men in the study did not express this senti-

ment. Some women commented that their friends and fam-

ily saw them as being someone who followed all the rules.

Becoming a smoker allowed these women to have the allure

of being risk takers and feeling accepted. In these instances,

tobacco smoking became an avenue for women to avoid

the perception that they would always choose to do what

was the right thing:

Then when I partook in it, then it was like, ‘Oh, she’s not the goodie-

goodie,’ you know, or that we thought she was. I guess, I mean it

kind of felt good, I guess, just ‘cause I proved like I’m not, I can be

bad too. Like, I don’t have to be good all the time. [Female]

Dating only non-smokers

Participants indicated that being a smoker could limit

dating options. Women believed that the most eligible men

would prefer to date a non-smoking woman. Some women

indicated that they would quit smoking to date the right

person, usually a man with a college degree. Their belief

that college educated men did not want a woman who

smoked tobacco led them to consider quitting smoking. All

non-smoking men and women commented that they would

not date a smoker:

A lot of my friends, they just say…the guy that you want is not

going to accept that….if it was a really good guy…and if he

wanted me to…I would stop….Just because I know it’s the best

thing for me…I just need that reason to…The guy I want, you

know, I want him to have a college degree. [Female]

Link with marijuana

Smoking marijuana first

Tobacco use rarely led to marijuana use, instead, marijuana

led to smoking tobacco products. Tobacco, especially Black

and Milds, were smoked immediately after using marijuana.

Many participants believed that tobacco use in the Black

community only occurred when smoking marijuana. A

woman noted, ‘I rarely know people who smoke blacks by

itself without having weed along or have ever smoked

weed. Like blacks and weed go together’. Another

participant stated:

I think Black and Milds are marketed more in the urban communi-

ties and it’s like a step below weed really, but a lot of African

Americans see, especially young, see cigarettes as being bad or

worse than either one of those two. [Male]

Boosting their marijuana high

Several participants indicated that they started smoking

tobacco after hearing that tobacco boosted the high feeling

that marijuana provided. For these participants, marijuana

P.R. Jones et al.

was the sole reason for initiating tobacco use. Black and

Milds were also used as a substitute when marijuana was

unavailable. Participants stated that smoking Black and

Milds replicated, in a small sense, the high they received

from marijuana. Many participants viewed Black and Milds

as a medium to smoke marijuana. Participants knew that

adding marijuana to the Black and Milds made it harder to

detect the illegal substance:

We were talking about, like ‘Do you know people that actually

smoke these cigars [blacks], or are they just a tool for people that

smoke marijuana pretty much?’ And the consensus has been it’s

just for marijuana smokers….Nobody buys those cigars to smoke

them. [Male]

Smoking, adulthood and success

Some young adults saw smoking as a part of becoming an

adult. Smoking was a way to demonstrate autonomy and

independence from their parents and authority figures.

Purchasing and smoking cigarettes was a demonstration of

legally being able to make decisions about their lives:

I was 19, had my own crib. So it was just like I could do it….when

I got out on my own, it was just like I’m going to do what I want

to do. And just live my life the way I want to live it. And with

having the freedom of my own apartment, I could do it. So and I

was of age to buy it. It wasn’t like I had to go through somebody

to get it for me. So I figured, hey, I’m of age, so it’s OK for me to

do it. [Female]

Having a life plan

Former smokers and those who never smoked tobacco indi-

cated that they had a vision for their lives. They believed

that smoking tobacco would hinder their ability to be

successful. Former smokers discussed that they stopped

smoking when they wanted to improve their lives by going

to school/college or obtaining new friends. Former smokers

mentioned that they felt better about themselves when they

substituted activities for smoking. The additional activities

provided structure and a daily road map that left little time

for smoking tobacco or marijuana. Former smokers dis-

cussed that they felt more successful after quitting because

it allowed them to be more productive:

When you get up in the morning, other people will be feeling like,

‘Well, I need to smoke.’….I get on the phone or I motivate myself,

like you’re going to start the day off like this….I get myself a daily

plan to let me know what I’m going to do….throughout the day,

then I have no time for smoking. [Female]

Success

Achieving success in their lives was important to the partici-

pants. Participants believed that smokers may not be as

successful in life as non-smokers. Participants smoked to

escape stress, the pressures of life and ‘the thought of not

being successful’:

Surviving pretty much. I think that would be the main reason why

people smoke, to get that thought out of their mind and try to

make it go away a little bit, I guess…I think sometimes it’s over-

whelming when they realize, OK, I got to do this…and then I think

they just want to just escape from it all. [Male]

Self-reflection: potential tobacco control interventions

Participation in the study may have led participants to

think about the reasons that they smoked tobacco. After

enrolling in the study, some smokers commented on having

conversations about smoking with friends and family and

identifying events that triggered the urge to smoke:

I was sitting around my two friends and I’m like, ‘why do we

smoke? Like why do we actually smoke cigarettes?’ And I’m like -

we actually had a conversation, like, ‘How long have you been

smoking?’….And they were just recognizing things…when they

smoke…naming things they do to make them smoke. And most of

the time it’s, it’s after you’re done doing something or if you’re

angry or, or if you’re driving, if you’re done eating, things like that.

[Female]

This self-reflection seemed to have the greatest impact on

some participants’ thoughts about quitting smoking. In

contrast, few participants were able to provide specifics

about tobacco campaigns they had viewed or heard. The

participants believed that effective campaigns should be

interesting and provide health statistics and identified key

aspects for inclusion in tobacco control campaigns. In partic-

ular, participants believed that tobacco control campaigns

needed to provide facts about tobacco and its connection to

marijuana use and the health risks of using marijuana. They

also advocated for campaigns that linked being a non-smo-

ker with increased financial success and personal happiness.

These young adults believed that tobacco control campaigns

needed blunt messages to catch adolescents and young

adults’ attention. They wanted campaigns that engaged them

in an unusual and powerful manner. A male, non-smoker,

stated: ‘I actually have a magnet on my refrigerator that says,

‘Tobacco kills 400,000 people a year. Now that’s terrorism.’

Participants believed that some interventions designed

for minority young adults were simplistic and not relevant

JAN: ORIGINAL RESEARCH Smoking in Young Blacks

to their lives. They discussed wanting personalized

interventions that demonstrated an interest in their lives.

They suggested that interventions designed by individuals

who understood their lives would increase the effective-

ness of the intervention. Interventions that included his-

torical references to Black life, such as slavery, were also

discussed:

I think marketing kind of gets off base on it and it seems really

hokey….Like the 5,4,3,2,1 healthy kids goal kind of things…that is

so corny….when we hear it, we’re like, ‘Oh, like come…on,’….if

you want to do it….Don’t have Jim from the marketing department

do it. [Male]

If we were reminded how many Black people were slaves picking

tobacco and what that, those two things together did for the coun-

try on our backs, it might be a little bit more to help people, you

know, be like ‘[Forget] that.’ [Male]

Discussion

In general, research on African Americans and tobacco has

focused on the effects on disease and the marketing of

tobacco products. The findings in our study illustrated that

the attitudes and beliefs of young Black adult smokers may

not be indicative of whether a young adult uses tobacco

products. As in this research, previous studies that explored

smoking identity in college students found that some indi-

viduals who smoked did not consider themselves to be

smokers (Thompson et al. 2007, Ridner et al. 2010). In our

study, participants also based their smoking identity on the

amount and frequency of tobacco consumption. The varied

definitions of smoking identities used by young adults indi-

cate a need for nurses and other healthcare professionals to

use appropriate language and questions when assessing

smoking status and behaviours.

Few participants viewed the price of cigarettes or Black

and Milds as an impetus to quit smoking. Studies have

found that the psychosocial benefits of smoking, for exam-

ple, stress reduction, may be a factor in why smokers may

not cease smoking (Niaura et al. 2002, Childs & de Wit

2010). In contrast, a study found that young adults smok-

ing rates were influenced when cigarette taxes increased

(Tauras 2004, Martire et al. 2011).

The interviews confirmed the results of other studies that

relationships have an important role in an individual’s

smoking identity. The smoking identity of many of partici-

pants in this study was influenced by how socially accept-

able their family and friends found tobacco use.

Participants who smoked often spent time with other

smokers or had family members who also smoked. Current

smokers identified that quitting smoking was easier when

they surrounded themselves with non-smokers, in essence

creating a supportive network helps to quit smoking. These

finding are similar to those of other investigators who noted

that social networks may play an important role in smoking

cessation (Patterson et al. 2004, Reitzel et al. 2012) and

that smoking spreads through social networks (Christakis

& Fowler 2008).

Traditionally, tobacco use has been viewed as a gateway

to illicit drug use and research has found an association

between tobacco use and future marijuana use (Goldberg

et al. 2009). For some of our participants, smoking ciga-

rettes was less acceptable than cigars. Many participants

used tobacco only to accentuate their experience after mari-

juana use. Our findings are similar to another study, which

found that a small portion of African Americans smoked

cigars [blacks] only to enhance marijuana’s effects (Jolly

2008). Most participants in this study started smoking pri-

marily to ‘boost their high’ with marijuana use. This finding

suggests that smoking initiation in Blacks may differ for

Whites as marijuana may be a precursor to tobacco use in

young Black adults.

Young adults in this study described smoking tobacco

products and marijuana as a way of coping with their fears

of success and the anxiety related to those fears. Attending

college may have increased the sense of vulnerability and

stress that these young adults experienced about whether

they would succeed in their efforts to improve their lives.

However, many participants identified that working

towards a goal, such as a college education, increased the

likelihood that they would cease using tobacco products.

The participants belief that success was linked to college

education is supported by studies that show that

college educated young adults smoke less than non-college

educated young adults (Barbeau et al. 2004, Green et al.

2007).

Interventions that promote reflection on smoking behav-

iour, effects and influences may be effective in tobacco pre-

vention and control with this group of young adults. Self-

reflection is the process of examining oneself to understand

perceptions, feelings and experiences. Reflective practice

interventions have been used to transform and improve the

practice of nurses (Beam et al. 2010). Self-reflection may be

an effective component of a tobacco prevention and cessa-

tion intervention for young adult Blacks.

Although some participants discussed links between

slavery and tobacco, the irony of a product that is detri-

mental to their health, marketed to African Americans and

labelled ‘blacks’ by consumers, was not discussed by these

P.R. Jones et al.

participants. Prior research has shown that the tobacco

industry strategically focused marketing campaigns on

young Black adult (Yerger et al. 2007). The lack of discus-

sion on the marketing of tobacco products and associated

health effects may be indicative of the success of the

tobacco marketing to this population. While some knew of

health risks associated with smoking, this had little effect

on their smoking behaviour.

Gender played a role in the smoking status in this study.

Some of the women in the study perceived that being a

smoker influenced both how they were viewed by their

family and friends, and their ability to find a long-term

mate. Similar results were found in other studies. In a study

of women, Graham et al. (2006) found that non-cohabita-

tion increased the odds of women being a smoker and

Weden et al. (2006) found that women who are unem-

ployed are more likely to be smokers than men and may be

less likely to quit smoking due to stress.

Limitations

The study was limited to a convenience sample of Black

young adults in the Midwest. The attitudes and beliefs may

differ among African Americans living in different areas of

the country. Additionally, a limited number of respondents

provided feedback about the preliminary results. However,

those who provided feedback did validate the study’s find-

ings. Also, the majority of study participants were college

students and the study results may not reflect the attitudes

and beliefs of people not enrolled in college.

Conclusion

Nurses and other healthcare providers have an important

role in preventing tobacco use and promoting tobacco

cessation. The study indicates that healthcare providers

need to assess how tobacco use fits into the context of

young adult’s lives. The value of the conversation in initiat-

ing reflection on the part of the smoker was identified as a

potentially useful strategy to promote smoking cessation.

These young adults’ knowledge and perceptions of tobacco

use were shaped by their relationships with family members

and friends. They initiated smoking primarily to enhance

the effects of their marijuana use. Marijuana seemed to be

the point of entry to tobacco use for the young adults. In

this study, the young adults who smoked believed that they

had fewer life options. Understanding the attitudes and

beliefs of these young adults may be helpful in develop-

ing relevant culturally appropriate interventions for this

population.

Funding

This project was supported by a Dean’s grant from the

University of Nebraska College of Nursing.

Conflict of interest

No conflict of interest has been declared by the authors.

Author contributions

All authors have agreed on the final version and meet at

least one of the following criteria [recommended by the

ICMJE (http://www.icmje.org/ethical_1author.html)]:

• substantial contributions to conception and design, acquisition of data, or analysis and interpretation of

data;

• drafting the article or revising it critically for important intellectual content.

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