The interaction of curriculum type and implementation method on 1-year smoking outcomes in a school-based prevention program

Studies have shown that the effectiveness of programs or curricula may depend in part on who delivers the material. In adolescent health education programs, peer leaders are often recruited to implement programs because they are more persuasive to other adolescents than adults. Teachers also systematically vary how groups are constructed in school-based health education programs. This study compared the effects of three leader and group selection methods within the context of two tobacco prevention programs. Eight schools received a social influences program (Chips) and eight received a program with a multicultural emphasis (Flavor). Within these 16 schools 84 classrooms consisting of 1486 students were randomly assigned to one of three leader and group creation conditions: (i) leaders defined as those who received the most nominations by students and groups created randomly (random group), (ii) same as (i) but groups created by assigning students to the leaders they nominated (network), and (iii) leaders and groups created by teachers (teacher). One year follow-up data showed that main effects of the curriculum and network assignments were non-significant on smoking initiation when entered alone. Interaction terms of curriculum and assignment methods, however, were significant such that the network and teacher conditions were less effective than the random group condition with Chips, and more effective than random group condition with Flavor. These data show that school-based prevention programs should be evaluated in light of who implements the program. Even a peer-led program will be differentially effective based on how leaders are selected and how groups are formed, and this effect may be curriculum dependent.

A randomized intervention of smoking for adolescents in urban Wuhan, China

BACKGROUND

Tobacco use is a significant public health problem in China. Culturally specific smoking prevention programs are needed for Chinese adolescents. This study evaluated a school-based smoking prevention curriculum with a social normative approach developed in the United States for adolescents in urban Wuhan, China.

METHODS

As a randomized trial, the intervention was implemented in 1998 with 7th grade students in seven schools with seven matched control schools. Multilevel logistic regression models were used to compare ever and recent (past-month) smoking behaviors for the control and program conditions.

RESULTS

At the 1-year follow-up, smoking had increased more rapidly in the control schools than in the program schools. The odds of baseline nonsmokers initiating smoking did not differ between the program and control groups (OR=1.08 with 95% CI=0.71, 1.64). The program prevented progression to recent smoking among boys who were baseline ever smokers. Among boys who were recent smokers at baseline, the prevention program significantly reduced risk of remaining recent smokers at follow-up (OR=0.45 with 95% CI=0.23, 0.88).

CONCLUSIONS

This social normative smoking prevention curriculum did not demonstrate a significant primary prevention effect but showed potential for secondary prevention. Culturally specific smoking prevention programs are needed for Chinese adolescents.

Influences affecting adolescent smoking behavior in China

This study examined multiple influences on the use of tobacco by adolescents in China. Using the theory of triadic influences as a guide, we selected interpersonal, attitudinal/cultural, and intrapersonal constructs from baseline data to predict adolescent smoking 1 year later. We used prospective data from middle and high school students (N = 11,583) and their parents from the China Seven Cities Study, a longitudinal study that is evaluating the effects of changing economic and social factors on health behaviors including tobacco use. A multilevel regression analysis provided some support that each of the influences in the theory of triadic influences affects adolescent smoking in China. After adjusting for important confounders including age, gender, socioeconomic status, and smoking behaviors (lifetime and past 30-day) at baseline, we found significant risk factors within each of the three categories, including interpersonal influences (parental monitoring, good friend smoking, and peer smoking), attitudinal/cultural influences (school academic ranking, initial liking of smoking, and the meaning of smoking), and intrapersonal influences (susceptibility to smoking, and low self-confidence to quit smoking). Results suggest that the etiology of smoking among adolescents in China might be similar to that observed in western countries and that some of the techniques used successfully in prevention programs in those countries might be useful guides when developing prevention programs in China.

Perceptions of ceremonial and nonceremonial uses of tobacco by American-Indian adolescents in California

BACKGROUND

American-Indian adolescents have the highest tobacco use prevalence of all ethnic groups in the United States. Although much has been written about the role of tobacco in traditional Native-American cultures, little is known about modern-day perceptions of tobacco among American-Indian adolescents.

METHODS

This study conducted focus groups of 40 American-Indian adolescents in urban and rural areas of Southern California. Participants discussed the role of traditional ceremonial tobacco use in their lives, the use of commercial tobacco as a substitute for sacred tobacco, the perceived safety of traditional versus commercial tobacco, and the perceptions of American-Indian imagery in tobacco advertising.

RESULTS

Many American-Indian adolescents may be introduced to traditional tobacco use at early ages. Smoking is viewed as a sign of respect for the elders, but there are acceptable ways for adolescents to participate in ceremonies without inhaling smoke. Commercial cigarettes often are substituted for homegrown tobacco at ceremonies and events. Traditional tobacco was perceived as less dangerous than commercial tobacco because it does not contain chemical additives. However, respondents still perceived that smoking traditional tobacco and breathing tobacco smoke conferred health hazards. Participants found the use of American-Indian imagery in tobacco advertising offensive and stereotypical. Indian casinos were mentioned frequently as places where smoking occurred.

CONCLUSIONS

Continued health education efforts are needed to decrease habitual use of commercial tobacco products and secondhand smoke exposure among American-Indian youth. Further research is needed to identify ways for American-Indian youth to participate in their cultural traditions while minimizing their risk for tobacco-related diseases.

Unique contributions of meanings of smoking and outcome expectancies to understanding smoking initiation in middle school

BACKGROUND

Previous research has shown that meanings of smoking are highly predictive of smoking in middle school children. Three factors of meanings of smoking have been suggested in the literature: personal meanings, functional meanings, and social meanings. These conceptually derived factors of meanings of smoking have not previously been empirically studied.

PURPOSE

This study examined the factor structure of the Meanings of Smoking Index (MSI) to determine the unique contribution of meanings of smoking and positive outcome expectancies to smoking behavior in middle school children.

METHODS

A multiethnic sample of 2,247 eighth-grade students enrolled in 24 middle schools in greater Los Angeles completed a paper-and-pencil survey in class.

RESULTS

Four factors of the MSI emerged (functional, personal, social image, and weight concern). Positive outcome expectancies and each of the four factors of the MSI predicted lifetime smoking in a multivariate model.

CONCLUSIONS

Meanings of smoking were empirically distinct from positive outcome expectancies. Adolescents who endorsed personal and functional meanings were more likely to smoke. Social image and weight concern meanings were negatively related to smoking after controlling for all other meanings. Meanings of smoking may prove to be important and modifiable mediators of smoking and therefore useful in future prevention studies.

Peer influences on adolescent cigarette smoking: a theoretical review of the literature

This article reviews several classes of theories to elucidate the relationship between adolescent cigarette smoking and friends' cigarette smoking. Perceived influence theories hinge upon an adolescent's perception of friends' smoking behavior. External influence theories are those in which friends' smoking behavior overtly influences adolescent smoking. Group level theories examine how differences at the level of subculture, gender, and race/ethnicity influence the relationship under study. Network theories are also discussed. A model integrating relevant theories into a longitudinal model representing friend influences on adolescent smoking is presented, along with implications of the results presented for adolescent tobacco prevention programs.

Cultural/interpersonal values and smoking in an ethnically diverse sample of Southern California adolescents

In ethnically diverse school contexts, values from multiple cultures might influence adolescents' attitudes and behaviors. This study developed scales to assess cultural values among Southern California 6'-grade adolescents (N=2281) and evaluated the associations between values and smoking. The scales assessed values salient in many Hispanic and Asian cultures: Respect for Adults (e.g., filial piety, respeto), Interpersonal Harmony (e.g., saving face, simpatia), and Differentiated Gender Roles (e.g., machismo). In cross-sectional and one-year longitudinal models, Respect for Adults and Interpersonal Harmony were associated with a lower risk of lifetime smoking. The associations were significant even after controlling for demographic characteristics, friends' smoking, and parents' smoking, indicating that values influence adolescents' behavior over and above the effects of modeling and peer influence. Increased understanding of adolescents' values could inform the creation of smoking prevention programs for ethnically diverse adolescents.

Definitive and palliative radiotherapy for cervix cancer in the elderly

The elderly population is increasing in number. Aggressive therapeutic intervention in this patient group may not always be possible because of age, the presence of co-morbidity, and poor functional status. Hence, individualized management of cervix cancer (CC) in the elderly is often practiced. Because of the preceding consideration, the cases of 79 women 65 years of age and older with CC treated with radiation over the last 20 years were reviewed. The cases were classified into two groups--those who were aggressively irradiated (group 1: 43 patients) and those managed less intensively for palliation (group 2: 36 patients). Local tumor control, complications, and survival were assessed. There were fewer extremely aged (> or = 75 years of age) women (p = 0.006) with advanced stage disease (p = 0.012) in group 1 than in group 2. Also, group 1 women experienced fewer treatment failures (p < 0.0003) and more of them were alive and well at last follow-up (p < 0.005) than those from group 2. The median survival periods for groups 1 and 2 were 60 months and 11 months, respectively (p < 0.0001); the corresponding 5-year crude survival rates were 54% and 19%, respectively (p = 0.002). Two women required remedial surgery for bowel obstruction/perforation after irradiation, and one patient sustained chronic radiation cystitis.

Whole-body [18F]fluoro-2-deoxyglucose positron emission tomography scan staging prior to planned radical hysterectomy and pelvic lymphadenectomy

The aim of the study was to determine the effectiveness of whole-body [18F]fluoro-2-deoxyglucose positron emission tomography (FDG PET) imaging in properly selecting candidates for radical hysterectomy who are at low risk for subsequent chemoradiation. Retrospective study of 14 women undergoing planned radical hysterectomy and pelvic lymphadenectomy with clinically localized cervical cancer and either negative or inconclusive metastatic nodal disease by PET scan was performed. Pelvic lymph nodes were clearly negative by FDG PET scan in 12 of the 14 women. Two women had focal FDG uptake suspicious, although not definitive, for nodal metastasis, and pelvic nodes were positive at surgery in both. Computed tomography (CT) scan failed to detect nodal disease in either woman. Neither PET nor CT was effective at detecting parametrial disease, and both also failed to detect the primary tumor in some cases. Women with FDG PET scans that are clearly negative for nodal disease are good candidates for radical hysterectomy and are at low risk for subsequent chemoradiation.

Do popular students smoke? The association between popularity and smoking among middle school students

BACKGROUND

Several studies have shown an association between popularity and behavior, indicating that popular people tend to reflect the norms of their group. Among adolescents, it has been hypothesized that popular students are more likely to smoke, especially in schools with high smoking prevalence.

METHODS

Data were collected on friendship patterns and smoking from 1,486 sixth and seventh graders in 16 middle schools in southern California. Susceptibility to smoke was measured as not stating a commitment not to smoke in the future, and smoking as ever taken a puff or smoked a whole cigarette. We measured popularity as the number of times a student was chosen as a friend. Multivariate logistic regression was used to correlate popularity with susceptibility to smoke and smoking at follow-up controlling for baseline outcomes, demographic characteristics, and clustering within schools.

RESULTS

Popularity was associated with increased susceptibility to smoke (Adjusted Odds Ratio [AOR] = 5.64, p < .001) and smoking (AOR = 5.09, p < .05) over the 1-year interval between surveys. Although the association was strongest for non-White boys, we did not find evidence of interactions between popularity and gender or ethnicity.

CONCLUSIONS

Popular middle school students were more likely to become smokers compared to their less popular peers. Although there seems some difference in the association by gender and ethnicity, the evidence does not suggest subgroup effects in this population. Implications for the study of adolescent smoking and prevention programming are discussed.

Internet Accessibility and Usage among Urban Adolescents in Southern California: Implications for Web-Based Health Research

The World Wide Web (WWW) poses a distinct capability to offer interventions tailored to the individual's characteristics. To fine tune the tailoring process, studies are needed to explore how Internet accessibility and usage are related to demographic, psychosocial, behavioral, and other health related characteristics. This study was based on a cross-sectional survey conducted on 2373 7th grade students of various ethnic groups in Southern California. Measures of Internet use included Internet use at school or at home, Email use, chat-room use, and Internet favoring. Logistic regressions were conducted to assess the associations between Internet uses with selected demographic, psychosocial, behavioral variables and self-reported health statuses. The proportion of students who could access the Internet at school or home was 90% and 40%, separately. Nearly all (99%) of the respondents could access the Internet either at school or at home. Higher SES and Asian ethnicity were associated with higher internet use. Among those who could access the Internet and after adjusting for the selected demographic and psychosocial variables, depression was positively related with chat-room use and using the Internet longer than 1 hour per day at home, and hostility was positively related with Internet favoring (All ORs = 1.2 for +1 STD, p < 0.05). Less parental monitoring and more unsupervised time were positively related to email use, chat-room use, and at home Internet use (ORs for +1 STD ranged from 1.2 to 2.0, all p < 0.05), but not related to at school Internet use. Substance use was positively related to email use, chat-room use, and at home Internet use (OR for "used" vs. "not used" ranged from 1.2 to 4.0, p < 0.05). Self-reported health problems were associated with higher levels of Internet use at home but lower levels of Internet use at school. More physical activity was related to more email use (OR = 1.3 for +1 STD), chat room use (OR = 1.2 for +1 STD), and at school ever Internet use (OR = 1.2 for +1 STD, all p < 0.05). Body mass index was not related to any of the Internet use-related measures. In this ethnically diverse sample of Southern California 7(th) grade students, 99% could access the Internet at school and/or at home. This suggests that the Internet is already a potential venue for large scale health communication studies. Adolescents with more psychosocial risk factors or detrimental health behaviors were more likely to use the Internet. Therefore, if used properly, Internet interventions could effectively address the high risk populations. Additional research is needed to gain a more complete understanding of the positive and negative consequences of Internet use among adolescents.

Smoking prevention for ethnically diverse adolescents: 2-year outcomes of a multicultural, school-based smoking prevention curriculum in Southern California

BACKGROUND

Effective school-based curricula are needed to prevent smoking among ethnically diverse adolescents. This study evaluated a multicultural smoking prevention curriculum in ethnically diverse Southern California middle schools.

METHODS

Students in 24 middle schools (N = 3157 sixth graders) received the multicultural curriculum, a similar curriculum without references to cultural issues, or a control condition. Odds ratios for experimentation with smoking over a 2-year period were calculated.

RESULTS

The multicultural program was associated with a lower risk of smoking between sixth and eighth grade, relative to the control group. Program effects varied according to the ethnic composition of the schools. In schools with predominantly Hispanic populations, the multicultural curriculum was more effective than the control, but the standard curriculum was not. In schools with predominantly Asian or multicultural populations, the standard curriculum was more effective than the control, but the multicultural curriculum was not. Analyses stratified by ethnicity within the schools revealed that the multicultural curriculum was effective among Hispanic students within predominantly Hispanic schools, but not among Hispanic students within predominantly Asian/multicultural schools.

CONCLUSIONS

Smoking prevention for adolescents in culturally diverse school contexts is a challenge. In this study, a multicultural curriculum was most effective among Hispanic students in predominantly Hispanic schools. Further research is needed to determine the best ways to prevent smoking in predominantly Asian and multicultural schools.

Acculturation, physical activity, and fast-food consumption among Asian-American and Hispanic adolescents

Previous studies have implicated acculturation to the US as a risk factor for unhealthy behaviors among Hispanic and Asian-American adolescents, including substance use, violence, and unsafe sex. This study examined the association between acculturation and obesity-related behaviors-physical activity and fast-food consumption-among 619 Asian-American and 1385 Hispanic adolescents in Southern California. Respondents completed surveys in 6th and 7th grade. The 6th grade survey assessed acculturation with the AHIMSA acculturation scale and a measure of English language usage. The 7th grade survey assessed frequency of moderate-to-intense physical activity and frequency of eating fast-food. Multiple regression analyses included acculturation and demographic covariates as predictors of physical activity and fast-food consumption. Acculturation to the US, assessed in 6th grade, was significantly associated with a lower frequency of physical activity participation and a higher frequency of fast-food consumption in 7th grade. The significant associations persisted after controlling for covariates and were consistent across gender and ethnic groups. Results suggest that acculturation to the US is a risk factor for obesity-related behaviors among Asian-American and Hispanic adolescents. Health promotion programs are needed to encourage physical activity and healthy diets among adolescents in acculturating families.

Hostility, depressive symptoms, and smoking in early adolescence

Using logistic and multiple regression, we examined the association between hostility, level of depressive symptoms, and smoking in a sample of 1699 ethnically diverse students in California. Self-reports were collected twice from each student, at the beginning of the 6th and 7th grade years. Among 6th graders who had not smoked, depressive symptoms and hostility were associated with smoking initiation by the 7th grade. Among those students who had already tried smoking, increases in depressive symptoms and hostility were associated with more frequent smoking. The association between hostility and smoking was stronger for students reporting higher levels of depressive symptoms.

Family characteristics and smoking among urban and rural adolescents living in China

BACKGROUND

Adolescent smoking is a public health concern in China. Although the family is an important social influence in China, few associations among family characteristics and adolescent smoking have been examined using Chinese samples.

METHODS

Survey data on psychosocial variables and smoking were collected from a sample of 3629 7th grade adolescents (46% female; 54% male; mean age 12.7 years) in Wuhan, China. For adolescents, past 30-day smoking, family relationships, parents' negative sanctioning of smoking, parents' agreement with smoking, and parents' smoking behaviors are assessed. To account for the clustered data structure, hierarchical logistic regression analyses controlling for demographics (urbanization, age) examined the independent and multivariate effects of family characteristics for each gender.

RESULTS

Girls are less likely than boys to report smoking and are more likely to report positive family relationships, and having parents with negative attitudes toward them smoking. Positive family relationships and age were strongly associated with smoking for both genders. No significant differences exist by gender.

CONCLUSION

These findings suggest that the quality of family relationships are important for adolescent female and male smoking in China.

A new measure of smoking initiation and progression among adolescents

OBJECTIVE

To develop a new measure of smoking initiation and progression among adolescents.

METHOD

This study used data from 2504 regular and alternative high school students to evaluate the psychometric properties of a new 3-item, 5-stage measure of smoking initiation and progression.

RESULTS

The categorization method showed good 4-week test-retest reliability (.83 among boys and .87 among girls). The demographic distribution of adolescents into stages was consistent with previous research.

CONCLUSION

This 5-stage classification method could be a useful framework for describing variation along the smoking up-take and progression continuum.

Emotional intelligence and acculturation to the United States: interactions on the perceived social consequences of smoking in early adolescents

High emotional intelligence (EI) is associated with decreased adolescent smoking. Acculturation to the United States is a risk factor for adolescent smoking. High EI may buffer the relationship between acculturation to the United States and perceptions of the social consequences of smoking (PSC). Emotional intelligence is the ability to: accurately perceive, appraise, and express emotion; access and/or generate feelings in facilitating thought; understand emotion and emotional knowledge; and regulate emotions. Emotional intelligence (measured by the Multifactor Emotional Intelligence Scale, Adolescent Version), acculturation, and PSC were assessed in 2001 from 416 Southern California sixth graders (47% boys; mean age = 11.3 yrs; 32% Hispanic/ Latino, 29% Asian/Pacific Islander, 13% White, 19% Multiethnic, 6% Other). There was a significant EI x US acculturation interaction (p < 0.01) suggesting that those with high EI perceived more social consequences associated with smoking. As the U.S. population becomes increasingly diversified, identifying protective variables and designing effective prevention programs for adolescents of diverse ethnic and cultural backgrounds becomes important.

Acculturation, physical activity, and fast-food consumption among Asian-American and Hispanic adolescents

Previous studies have implicated acculturation to the US as a risk factor for unhealthy behaviors among Hispanic and Asian-American adolescents, including substance use, violence, and unsafe sex. This study examined the association between acculturation and obesity-related behaviors-physical activity and fast-food consumption-among 619 Asian-American and 1385 Hispanic adolescents in Southern California. Respondents completed surveys in 6th and 7th grade. The 6th grade survey assessed acculturation with the AHIMSA acculturation scale and a measure of English language usage. The 7th grade survey assessed frequency of moderate-to-intense physical activity and frequency of eating fast-food. Multiple regression analyses included acculturation and demographic covariates as predictors of physical activity and fast-food consumption. Acculturation to the US, assessed in 6th grade, was significantly associated with a lower frequency of physical activity participation and a higher frequency of fast-food consumption in 7th grade. The significant associations persisted after controlling for covariates and were consistent across gender and ethnic groups. Results suggest that acculturation to the US is a risk factor for obesity-related behaviors among Asian-American and Hispanic adolescents. Health promotion programs are needed to encourage physical activity and healthy diets among adolescents in acculturating families.

Exposure to televised alcohol ads and subsequent adolescent alcohol use

OBJECTIVE

To assess the impact of televised alcohol commercials on adolescents' alcohol use.

METHODS

Adolescents completed questionnaires about alcohol commercials and alcohol use in a prospective study.

RESULTS

A one standard deviation increase in viewing television programs containing alcohol commercials in seventh grade was associated with an excess risk of beer use (44%), wine/liquor use (34%), and 3-drink episodes (26%) in eighth grade. The strength of associations varied across exposure measures and was most consistent for beer.

CONCLUSIONS

Although replication is warranted, results showed that exposure was associated with an increased risk of subsequent beer consumption and possibly other consumption variables.

Stressful life events, smoking behavior, and intentions to smoke among and multiethnic sample of sixth graders

OBJECTIVES

Adolescent smoking has been associated with stressful life events. However, few studies have examined the associations between stress, smoking intentions, and smoking behavior among a multiethnic sample of adolescents.

METHODS

We compiled a checklist of stressful life events relevant to multiethnic youth and administered it to 1,074 sixth-grade students in urban Los Angeles.

RESULTS

The most frequently reported stressful events were similar across ethnic groups and generations in the USA: test taking, chores, and arguments with friends. The events reported as the most severe were disturbances in family life, such as: death, arguments between parents, and illness or injury. Whites and Latinos had reported higher levels of ever smoking and intentions to smoke than Asian/Pacific Islanders (PIs). On the positive family-related events scale Latinos scored higher than did whites or Asian/PIs. Whites scored higher than Latinos or Asian/PIs on both negative peer-related and negative personal-related events. Associations were observed between total stress, stressful life events, and smoking behavior and intentions to smoke. Total stress was associated ith ever smokers, smoking intentions within the next year and in high school over the entire sample. Negative peer-related events were associated with intention to smoke within the next year, among Latinos. Among Asian/PIs negative peer-related events were associated with intention to smoke within the next year and in high school. Negative school-related events were significantly associated with ever smoking and intentions to smoke in the next year and marginally associated with intentions to smoke in high school among children born in the USA whose parents were also born in the USA. Negative peer-related events and positive personal-related events were significantly associated with intentions to smoke in the next year among children born in the USA whose parents were immigrants.

CONCLUSIONS

Results suggest that negative peer- and school-related events may lead to increased risk of smoking behavior and intentions to smoke among multicultural adolescents.

Meanings of smoking and adolescent smoking across ethnicities

PURPOSE

To develop insight into population-specific meanings of smoking in our highly multicultural middle schools in order to provide effective and appropriate tools for smoking prevention efforts.

METHODS

We used focus group interviews to develop the Meanings of Smoking Index (MSI), a nine-item scale that uses a "mark all that apply" strategy to assess what smoking means to children who have tried smoking as well as to those who are susceptible to smoking. In 24 public and parochial middle schools in the greater Los Angeles area, 2336 7th graders (1483 Latino, 565 Asian/ Pacific Islander and 288 white, 55.2% of the sample was female) completed the MSI as part of a school-based trial of culturally-targeted smoking prevention strategies. Items were rank ordered according to salience (rate of endorsement) and relevance (strength of relationship with lifetime smoking) across the entire sample and separately for Hispanic/Latino, Asian/Asian-American and white respondents. Spearman correlation coefficient was used to compare results between ethnicities.

RESULTS

The most frequently endorsed meanings were similar across ethnicities. Magnitude of associations between smoking behaviors and meanings were dissimilar across ethnicities. The meaning with the strongest relationship to lifetime smoking for whites and Latinos was "it helps me study" (OR 3.4 and 2.6 respectively), and for Asians was "don't want to make another smoke alone" (OR 5.4).

CONCLUSIONS

We have shown previously that interventions on meanings of eating behaviors changed dietary behaviors in adolescents. The present findings suggest that meanings are powerful determinants of adolescent smoking in culturally diverse populations and could offer powerful intervention tools to prevent adolescent smoking.

A Family Member's Job Loss as a Risk Factor for Smoking Among Adolescents

Life events are associated with an increased likelihood of adolescent smoking. This study examined a family member's job loss as a predictor of smoking initiation over a 1-year period. Southern California students completed surveys in 6th and 7th grade. Of the 2,168 students, 252 (12%) reported that an adult in the household had lost a job within the past 6 months. Controlling for demographic, socioeconomic. educational, and parenting characteristics. 6th-grade never-smokers who reported a job loss were significantly more likely to have tried smoking by 7th grade and to have smoked in the past 30 days. Job loss for a household member is a risk factor for adolescents' involvement in problem behaviors such as smoking.

Exploring the cultural context of tobacco use: a transdisciplinary framework

Understanding culture is an essential key to reducing tobacco use. Conceptualizations of culture vary across scientific disciplines and theoretical orientations. Because of the complexity of the causes and effects of tobacco use, no single discipline has sufficient capacity to undertake a comprehensive approach to studying culture and tobacco. Transdisciplinary research offers a means of bridging disciplinary perspectives. This paper reviews epidemiological data on observed variation in smoking patterns across national groups, ethnicities and genders, and presents reasons for studying culture in tobacco control research. We discuss and contrast conceptualizations and specific definitions of culture and identify aspects of each conceptualization that are relevant to research on tobacco. We present a multilevel, multidimensional conceptual framework for transdisciplinary research teams to use to think together about the influence of culture on tobacco and of tobacco on culture. The framework challenges researchers to think about how the sociocultural context influences tobacco use at micro, meso, and macro levels. Finally, we offer suggestions for improving transdisciplinary research on culture and tobacco.

Project FLAVOR: 1-Year Outcomes of a Multicultural, School-Based Smoking Prevention Curriculum for Adolescents

To evaluate a multicultural smoking prevention curriculum, 16 schools were randomized to receive the multicultural curriculum or a standard curriculum and program effects on 1-year smoking initiation among 1430 never smokers were assessed. Hispanic boys who received the multicultural curriculum were less likely to initiate smoking than were those who received the standard curriculum; effects were insignificant among other groups. The prevention effect among Hispanic boys is encouraging, but additional research is needed to improve prevention effects among other groups.

The protective influence of spirituality and "Health-as-a-Value" against monthly substance use among adolescents varying in risk

PURPOSE

To investigate the influence of two potentially protective factors, Health-as-a-Value and spirituality, on monthly alcohol, cigarette, and marijuana use in two multiethnic groups of adolescents varying in risk.

METHODS

Three-hundred-eighty-two students from continuation/alternative high school, a population considered at risk for drug use, participated in the study. The other sample of 260 students was drawn from a medical magnet high school, and is considered to be at lower risk. Similar surveys containing measures of spirituality, "Health-as-a-Value," and monthly substance use, were distributed. Logistic regression analyses were performed.

RESULTS

The analyses revealed that spirituality was protective against monthly alcohol use and marijuana use in the lower risk sample. In the higher risk sample, spirituality was protective against all monthly use. "Health-as-a-Value" (HAV) was protective against monthly alcohol use in the low risk sample, and protective against all monthly use in the higher risk sample. Importantly, when both constructs were entered into the same model, spirituality and HAV were independently protective of all monthly use for the higher risk sample and of monthly alcohol use in the lower risk sample.

CONCLUSIONS

These findings extend earlier work on protective factors. "Health-as-a-Value" and spirituality may be protective against substance use in environments with different levels of use. Future studies should explore these findings in longitudinal analyses.

Characteristics of adolescents who provide neither parental consent nor refusal for participation in school-based survey research

Schools offer a convenient setting for research on adolescents. However, obtaining active written parental consent is difficult. In a 6th-grade smoking study, students were recruited with two consent procedures: active consent (parents must provide written consent for their children to participate) and implied consent (children may participate unless their parents provide written refusal). Of 4,427 invited students, 3,358 (76%) provided active parental consent, 420 (9%) provided active parental refusal, and 649 (15%) provided implied consent (parental nonresponse). The implied consent procedure recruited more boys, African Americans, students with poor grades, and smokers. This dual-consent procedure is useful for collecting some limited data from students who do not provide active consent or refusal.

Secular trends in adolescent never smoking from 1990 to 1999 in California: an age-period-cohort analysis

OBJECTIVES

We analyzed age, time period, and cohort effects on trends in adolescent cigarette smoking in California from 1990 to 1999.

METHODS

Data from subjects aged 12 to 17 years (n = 26 536; 50.4% male) from the California Tobacco Survey and the California Youth Tobacco Survey were analyzed, and never smokers were used as the outcome measure.

RESULTS

The proportion of never smokers increased from 60% for males and 66% for females in 1990 to around 70% for both sexes in 1999. Respondents were more likely to be never smokers if born in 1978 or later (i.e., aged 12 years or younger in 1990, when most tobacco control programs started in California).

CONCLUSIONS

The statewide antitobacco programs prevented adolescents from starting to smoke, primarily through a cohort effect.

Emotional intelligence and smoking risk factors in adolescents: interactions on smoking intentions

PURPOSE

To examine interactions between emotional intelligence (EI) and smoking risk factors on smoking intentions in adolescents.

METHODS

EI ios defined as the ability to: accurately perceive, appraise, and express emotion; access and/or generate feelings in facilitating thought; understand emotion and emotional knowledge; and regulate emotions. EI of 416 6th graders (53% girls) from middle schools in the Los Angeles area (mean age = 11.3 years; 32% Latino, 29% Asian/Pacific Islander, 13% white, 19% Multiethnic, 6% Other) was assessed with an abbreviated version of the Multifactor Emotional Intelligence Scale, Adolescent Version (MEIS). This was a competence-based measure assessing an individual's ability to perceive, understand, and manage emotion. Logistic regression models were fit to test interactions between EI and ever trying cigarettes, hostility, and perceived ability to refuse a cigarette from someone just met, on intentions to smoke in the next year.

RESULTS

High EI adolescents were more likely to intend to smoke in the next year if they had previously experimented with smoking. Those with low EI were more likely to intend to smoke if their perceived ability to refuse a cigarette offer from a person they just met was low or hostility level was high.

CONCLUSIONS

These preliminary results indicate that EI interacts with risk factors to reduce smoking intentions, and contributes evidence to a link between EI and smoking in adolescents.

A cultural psychology approach to "drug abuse" prevention

Much research on the etiology of adolescent drug use has focused on posited risk and protective factors at the level of the individual or small group. However, those proximal influences exist within a cultural context that also influences drug use. To prevent drug use in the diverse population of the United States, research is needed on the influence of the cultural context on adolescent drug use, including the effects of immigrating from one cultural or sociodemographic context to another, as well as the effects of living within two different cultural systems simultaneously. Theoretical models and research methods from cultural psychology and cultural sociology are well-suited to examine the cultural context of drug use. We examine causal mechanisms by which acculturation might affect drug use by using two paradigms to conceptualize culture: a stress/coping paradigm and a cultural values paradigm. Implications of cultural risk and protective factors for transdisciplinary research on drug abuse prevention are also discussed.

Social network predictors of bullying and victimization

This study examined whether bullies, victims, and aggressive victims (those who are both bullies and victims) differed on classroom social network variables, gender, and ethnicity. Survey data were collected from a primarily Latino and Asian sample of 1,368 Southern California 6th graders (mean age = 11.3 years). Logistic regression analyses were performed to determine whether network characteristics and ethnicity were associated with each of the outcome variables. Consistent with social cognitive theory, friends' participation in aggressive behaviors was positively associated with being a bully or an aggressive victim, and negatively associated with being a victim. Consistent with social dominance theory, the number of friendship nominations received was negatively associated with being a victim. Female bullies received fewer friendship nominations, but had a higher proportion of reciprocated friendships. Victims were disproportionately Asian. The findings suggest that bullying prevention efforts targeting highly aggressive students may also diffuse to their friends, and that assertiveness training in handling aggressive situations may successfully combat bullying and aggression.

A "drug abuse" theoretical integration: a transdisciplinary speculation

This article attempts to integrate previous articles in this issue into an integrative statement that addresses the concept of drug abuse and drug abuse prevention from a transdisciplinary perspective. It is argued that there are two types of drug misusers. There are drug experimenters who make mistakes and drug misusers who utilize drugs as a means to counteract a baseline state of "dis-balance." Prevention must address remediation of this dis-balance for the latter type of drug misuser.

Smoking behavior among urban and rural Native American adolescents in California

BACKGROUND

Previous studies have documented a high prevalence of tobacco use among Native American adolescents. However, little is known about the smoking behavior of Native American adolescents who live in urban areas. This study used statewide data from California to examine the smoking behavior and related psychosocial risk factors among Native American adolescents living in urban and rural counties.

METHODS

The Independent Evaluation of the California Tobacco Control Program conducted three population-based statewide surveys of 10th-grade California public school students in 1996, 1998, and 2000. Past-month smoking and psychosocial correlates were examined among 22,440 respondents, including 1060 Native Americans.

RESULTS

Native Americans had a 32% excess risk of past-month smoking compared with other ethnic groups. Smoking prevalence did not differ between urban (27.7%) and rural (29.3%) Native Americans. Native Americans reported higher access to cigarettes and exposure to smoking peers than other groups. Those psychosocial variables explained some, but not all, of the excess risk of smoking among Native Americans.

CONCLUSIONS

Effective smoking prevention and cessation interventions are needed for Native American adolescents in urban and rural areas of California.

Ethnic variation in parenting characteristics and adolescent smoking

PURPOSE

To examine ethnic variation in parenting characteristics and in associations among parenting characteristics and adolescent smoking, and to assess the strength of those associations separately by ethnic subgroup.

METHODS

Data were collected from a diverse sample (48.4% Hispanic/Latino, 22.9% Asian, 12.1% Non-Hispanic white, and 16.6% Multiethnic) of 1846 Southern California 6th-graders (mean age 11.3 years). Lifetime smoking and parenting characteristics (parental smoking status, adolescents' perceptions of parent-child communication, and parental monitoring) were assessed. Across ethnic groups, descriptive statistics for parenting and smoking variables were calculated and compared. Logistic regression analyses controlled for demographics (socioeconomic status, generation status, family structure, age, and gender) and interaction terms (parenting characteristics x ethnicity), and were also run separately by ethnicity.

RESULTS

Asian adolescents reported less parental monitoring than Latino/Hispanics and less parental communication than other ethnic subgroups. Odds ratios indicated parental monitoring (OR =.63; CI =.53-.74; p <.001) and parental communication (OR =.73; CI =.62-.86; p <.001) were protective whereas parental smoking (OR = 1.48; CI = 1.18-1.87; p <.01) was a risk factor for smoking. Relative to Latinos, parental monitoring (OR =.50; CI =.26-.95; p <.05) was more protective, and parental communication (OR = 2.44; CI = 1.15-5.17; p <.05) less protective for white adolescents. All parental characteristics were significantly associated with Latino/Hispanics smoking. Parental monitoring was significantly associated with Multiethnic and white smoking. No parenting characteristics were significant for Asians.

CONCLUSION

Ethnic differences in parenting characteristics and adolescent smoking should be considered when designing prevention curriculum. Future research should investigate the nature of parent-child communication among Asian immigrant populations.

Interpersonal conflict tactics and substance use among high-risk adolescents

Adolescents who use aggressive tactics to handle interpersonal conflicts may be at high risk for substance use, while adolescents who possess coping strategies to avoid or manage interpersonal conflict may be at lower risk for substance use. This study examined the association between interpersonal conflict tactics and substance use among 631 continuation high school students. Items from a modified Conflict Tactics Scale formed three factors: Physical Aggression, Nonphysical Aggression, and Nonaggression. Logistic regression analyses revealed that adolescents' ways of responding to interpersonal conflicts were associated with their substance use. Use of physical aggression was associated with a higher risk of cigarette, alcohol, marijuana, and other drug use. Use of nonphysical aggression was associated with a higher risk of cigarette and alcohol use. Use of nonaggressive conflict tactics was associated with a lower risk of cigarette use. Adolescents who respond to interpersonal conflicts in an aggressive manner, whether physical or verbal/psychological, may be at increased risk for substance use, while nonaggressive conflict management skills may be protective. Possibly, teaching adolescents nonaggressive techniques for handling interpersonal conflict may be a useful strategy for preventing both interpersonal violence and substance use.

Family harmony as a protective factor against adolescent tobacco and alcohol use in Wuhan, China

PURPOSE

To investigate the association between family harmony (FH) and tobacco and alcohol use (TAU) in Chinese adolescents.

METHODS

Participants completed a survey in 1998 as part of a larger study of adolescent health in Wuhan, China. Analyses were performed on subjects for whom complete data were available (n = 183; 50.8% male; mean age = 13.17 yrs, std dev = 0.59). Structural equation modeling was utilized to quantify the relationships between the FH, TAU, depression, and academic aptitude factors.

RESULTS

The conceptualized structural equation model was found to have a good fit to the data (CFI = 0.995; chi2 = 39.57 df = 38; p = 40). FH was a significant predictor of TAU (beta = -0.42, p < 0.05) and was protective. FH' was also negatively related to depression (r = -0.24, p < 0.05) and positively related to academic achievement/aptitude (r = 0.35, p < 0.05).

CONCLUSIONS

These central findings highlight the value and importance placed on FH within the Chinese culture. Future prevention programs may benefit by taking into account FH as a potential mediator of TAU in adolescents in China.

Youths' exposure to environmental tobacco smoke (ETS): associations with health beliefs and social pressure

Youths' exposure to environmental tobacco smoke (ETS) is a significant public health problem in the United States. This study examined the associations between health beliefs, social pressure, and exposure to ETS among high school youth. Data were collected in 65 schools in 18 California counties during the 1996-1997 school year as part of the Independent Evaluation of the California Tobacco Control, Prevention, and Education Program. The total sample (N = 6902) represents 10th grade California youth attending public schools. The multiple group analysis approach of structural equation modeling (SEM) was employed to test the associations of five constructs of the health belief model (HBM) and one construct of perceived social pressure with ETS exposure among nonsmokers and smokers. Results demonstrated that high perceived susceptibility to disease was significantly associated with lower levels of ETS exposure for both nonsmokers (beta = -0.11, P < .01) and smokers (beta = -0.20, P < .01). High social pressure to smoke was significantly associated with higher exposure to ETS for both nonsmokers (beta = 0.30, P < .01) and smokers (beta = 0.41, P < .01). Perceived barriers predicted lower exposure to ETS for nonsmokers (beta = -0.09, P < .01) but higher exposure for smokers (beta = 0.11, P < .01). Cues to action and self-efficacy were not significantly associated with ETS exposure among nonsmokers or smokers. These findings underscore the need to increase the awareness of harms associated with second hand smoke and alter social pressure, to minimize exposure to ETS.

Cancer of the cervix with endometrial extension treated by radiotherapy: a retrospective case-control study

BACKGROUND

Studies determining prognosis of cancer of the cervix with endometrial extension (CCEE) in a case-control fashion are scant.

METHODS

A case-control retrospective study of 20 women with CCEE and 16 patients with cervical cancer not extending to the endometrium (CCNEE) treated by radiation was undertaken. The patient groups were matched for age, disease stage, the presence of bulky/barrel-shaped tumor in the cervix, intercurrent illness, total radiation dose, and hemoglobin level. The overall mean follow-up was 54 months (range 8 to 218 months).

RESULTS

The numerical rates of local and systemic failure as well as 5-year survival were worse for patients with CCEE versus CCNEE. However, the observed differences were not statistically significant.

CONCLUSION

Involvement of the endometrium by cancer of the cervix seems to confer a worse outcome among cervical cancer patients treated by radiation alone.

Use of the fagerstrom tolerance questionnaire for measuring nicotine dependence among adolescent smokers in China: a pilot test

The validity of the Prokhorov adolescent version of the Fagerstrom Tolerance Questionnaire (FTQ) has not been demonstrated in assessing nicotine dependence among Chinese adolescents in China. Data for 48 tenth-grader 30-day smokers in Wuhan, China (ages 16-17 years), were analyzed. Two different item scoring protocols were used, and self-reports of smoking were validated with saliva cotinine. When items were scored using Protocol A, Cronbach's alphas were .42 and .63 for the 7-item and the 4-item scales, respectively; while using Protocol B, the alphas were .67 and .79 for the 7-item and 4-item scales, respectively. The total FTQ scores were significantly associated with self-reported smoking and saliva cotinine levels. These results support the reliability and validity of the Prokhorov FTQ.

Prior cigarette smoking initiation predicting current alcohol use: evidence for a gateway drug effect among California adolescents from eleven ethnic groups

Gateway drug theory provides a useful framework for understanding drug use among adolescent populations. Studies have reported a gateway effect of cigarette smoking on alcohol use among adolescents; but there is a lack of knowledge regarding ethnic differences in this effect. Using data from a cross-sectional survey in California, 11,239 subjects (46.3% male) from 31 high schools with at least 25% of total enrollment of Asian and at least 200 students with Asian ancestry entered the analysis. Among them, 6016 were ninth graders (mean age=14.3, S.D.=0.49) and 5223 were twelfth graders (mean age=17.3, S.D.=0.54). After controlling for seven variables, the risk ratio of last 30-day alcohol use among prior smoking initiators vs. noninitiators was 5.82 for non-Hispanic Whites, 4.25 for Blacks, 8.37 for Asian Indians, 3.99 for Chinese, 3.45 for Filipinos, 3.48 for Japanese, 5.41 for Koreans, 7.57 for Vietnamese, 4.02 for Mexicans, 2.64 for South/Central Americans, and 5.95 for adolescents with multiethnic background. Comparison of the 11 ethnic groups indicated that adolescents from different ethnic groups but with similar cultural background had a similar risk level; such pattern existed after controlling for acculturation, parents' monitoring, and school performance. The risk ratio did not differ by gender and grade. There is an association between prior cigarette smoking initiation and current alcohol use among adolescents from different ethnic backgrounds, including those of multiethnicity, which supports the generalizability of gateway drug effect of cigarette smoking on alcohol use. Studies should be conducted to investigate factors attributable to the ethnic variations of this association.

Independent evaluation of the California Tobacco Control Program: relationships between program exposure and outcomes, 1996-1998

OBJECTIVES

This study sought to determine the effects of the California Tobacco Control Program on tobacco-related attitudes and behaviors.

METHODS

In 1996 and 1998, a telephone survey was conducted among adults in randomly selected households in 18 California counties. Tenth-grade youths in 84 randomly selected high schools completed a written survey. In analyses conducted at the county level, differences in outcomes were regressed on an index of program exposure.

RESULTS

Among adults, program exposure was associated with decreased smoking prevalence rates, increased no-smoking policies in homes, and decreased violations of workplace no-smoking policies. Among youths, there was no effect of program exposure on outcomes.

CONCLUSIONS

These results suggest that the California Tobacco Control Program may have reduced adult smoking prevalence rates and exposure to environmental tobacco smoke.

Peer influences and access to cigarettes as correlates of adolescent smoking: a cross-cultural comparison of Wuhan, China, and California

BACKGROUND

Few studies have assessed the effects of access to cigarettes and peer influences on adolescent smoking in non-Western countries. Using samples characterized by two distinct cultural, social, and economic systems, this study evaluated the associations of friends' smoking and perceived access to cigarettes with adolescent smoking behavior in California and Wuhan, China.

METHODS

Survey data were obtained from 5870 eighth-grade students in the Independent Evaluation of the California Tobacco Control Program and 6992 seventh- to ninth-grade students in the Wuhan Smoking Prevention Trial. Odds ratios for lifetime and 30-day smoking, according to friends' smoking and perceived access to cigarettes, were calculated for boys and girls in both samples and compared.

RESULTS

California students were more likely than Wuhan students to have friends who smoked and to perceive easy access to cigarettes. The smoking prevalence was lower in Wuhan than in California, mainly due to the low smoking prevalence among Wuhan girls. Friends' smoking was strongly associated with smoking in both samples, and the strength of this association did not differ between the two cultures. Access to cigarettes was associated with a higher risk of lifetime smoking in both cultures and a higher risk of past 30-day smoking in California only.

CONCLUSIONS

Despite divergent tobacco control policy enforcement, social structures, and cultural contexts, similarities exist between Wuhan and California. The findings suggest support for adapting a social-influences-based smoking prevention program developed in the United States to the culturally specific needs of youth in Wuhan, China.

Receptivity to protobacco media and its impact on cigarette smoking among ethnic minority youth in California

Adolescents from different ethnic groups show different cigarette smoking prevalence rates, suggesting potential differences in receptivity to and influences from protobacco media. Understanding these differences will be helpful in tailoring smoking prevention and cessation programs for diverse adolescent populations in the United States. Data from cross-sectional surveys of 20,332 randomly sampled California boys and girls, 12-17 years of age, were analyzed. Results indicate that receptivity to protobacco media was lower among African Americans, Asian Americans, and Hispanics than among White youth. There was a consistent dose-response relationship between receptivity to protobacco media and 30-day cigarette smoking across ethnic groups. Having a cigarette brand preference was associated with the highest risk for cigarette smoking, having a favorite tobacco ad showed the lowest risk, while having received or being willing to use tobacco promotional items was associated with a moderate risk. After controlling for 13 covariates, the odds ratio for receptivity to protobacco media and 30-day cigarette smoking was significant for Whites (RR = 1.38, p < 0.01) and Hispanics (RR = 1.46, p < 0.01), but not for African American (RR = 1.05, p > 0.05) and Asian American (RR = 1.17, p > 0.05) youth. African American, Asian American, and Hispanic adolescents have a lower level of receptivity to protobacco media than do Whites. The association between media receptivity and 30-day cigarette smoking exists for all four ethnic groups without controlling for other smoking predictor variables, but only for Hispanics and Whites when other variables are controlled. Protecting adolescents from protobacco advertising influences is an important element in tobacco control among ethnic minority youth.

Are adolescents attempting to buy cigarettes on the internet?

OBJECTIVE

To assess the prevalence of, and demographic and smoking behaviour correlates of, attempting to purchase cigarettes via the internet among adolescent current smokers.

METHODS

A representative sample of 17 181 10th and 12th grade California students completed a written questionnaire on tobacco related attitudes and behaviour during the 1999-2000 school year. Logistic regression analyses were used to determine the variables associated with attempting to purchase cigarettes on the internet.

RESULTS

Among youth under 18 years of age who were current smokers (n = 1689), 2.2% (95% confidence interval 1.5% to 2.9%) reported attempting to purchase cigarettes on the internet. Attempted internet purchases were more likely among younger respondents, males, frequent smokers, and respondents reporting lower perceived availability of tobacco products from retail and social sources.

CONCLUSIONS

Few adolescent smokers in California surveyed during the 1999-2000 school year had attempted to obtain cigarettes from the internet. As internet access increases, future studies should examine whether internet cigarette vendors sell to minors and whether adolescents are purchasing cigarettes on the internet.

Adolescent smoking in Wuhan, China: baseline data from the Wuhan Smoking Prevention Trial

BACKGROUND

This study reports the prevalence of adolescent smoking in the urban and rural areas of Wuhan, China, the capital of Hubei Province, on the Yangtze River in central China.

METHODS

Smoking behavior was examined by age, gender, and urbanicity as part of the Wuhan Smoking Prevention Trial. Subjects included 6994 seventh- to ninth-grade students attending 22 randomly selected schools in urban and rural districts. Outcome measures included lifetime smoking, past-30-day smoking, established smoking (>100 cigarettes in lifetime), and susceptibility to smoking (absence of a firm commitment not to smoke).

RESULTS

Lifetime smoking prevalence was 47% among boys and 18% among girls. Past-30-day smoking prevalence was 16% among boys and 4% among girls. Established smoking prevalence was 2% among boys and 0% among girls. The prevalence of susceptibility to smoking was 31% among boys and 10% among girls. Smoking increased significantly with age (p<.0005). Susceptibility was more prevalent in rural areas than in urban areas (p<.05), but there were no urban-rural differences in lifetime, past 30-day smoking, or established smoking. Trend analyses revealed that smoking increased with age more rapidly among boys than among girls (p<.05). Smoking was more prevalent among rural boys than among urban boys, but it was more prevalent among urban girls than among rural girls (p<.05).

CONCLUSIONS

Adolescent smoking is a significant public health problem in China. Boys are at particularly high risk, as are girls living in urban areas. Effective smoking prevention programs for adolescents, as well as restrictions on tobacco industry marketing and youth access to tobacco, are needed to prevent tobacco-related morbidity and mortality in China.