Influences on Tobacco Use Among Urban Hispanic Young Adults in Baltimore: Findings From a Qualitative Study

Abstract

Background

Among Hispanics, lung cancer is the leading cause of cancer-related death for men and the second leading cause of cancer death for women in the United States. Despite recent growth in Baltimore City’s Hispanic population, few data exist on tobacco use behaviors in this group.

Objectives

The present research sought to explore the social and environmental influences and norms that encourage or discourage tobacco use among Hispanic young adults in Baltimore.

Methods

In collaboration with several community stakeholders, we conducted focus groups with Hispanic young adults 18 to 24 years old. Participants were recruited from a community-based service organization and invited to take part in one of four focus groups segregated by gender.

Results

A total of 13 young men and 11 young women participated. Data from these focus groups indicate that cultural identity and gender norms leverage substantial influence in young adults’ decision about whether, where, and with whom to smoke. The data also suggest multiple social and familial influences on their smoking and nonsmoking behaviors. Participants identified smoking practices and clear brand preferences that they feel distinguish Hispanics from other racial and ethnic groups. Despite acknowledging the high price of cigarettes, cost was not mentioned as a factor influential in their smoking decisions.

Conclusion

These results provide essential guidance for the development of appropriate tobacco prevention and cessation intervention strategies and policy recommendations to eliminate tobacco use among Hispanic young adults in Baltimore.

Tobacco use remains the single most preventable cause of disease and death in the United States, where exposure to cigarette smoking results in at least 443,000 premature deaths, 5.1 million years of productive life lost, and $96.8 billion in productivity losses annually.^1–4 In 1998, the Surgeon General issued the first report on tobacco use among four racial/ethnic minority groups in the United States and subsequent publications have highlighted the need for ongoing research on differences in tobacco use and resulting health disparities by race and ethnicity.^5–8 Research on the Hispanic population is particularly important as Hispanics represent the largest racial/ethnic minority group in the United States and accounted for one half of the nation’s growth from 2000 to 2006.^9,10 Although the prevalence of current smoking is lower among Hispanic adults (15.8%) compared with the general U.S. population (20.6%), lung cancer is the leading cause of cancer death in Hispanic men and the second leading cause of cancer death among Hispanic women in the United States.^11,12

In 2007, the prevalence of current smoking in Baltimore City exceeded Maryland’s statewide prevalence by more than 10%; similarly, the prevalence of smoking among minority adults in Baltimore City was 24.1% in 2006 compared with 15.8% statewide.^13,14 Although the Hispanic population has more than doubled in Baltimore City since 1990, few data exist on tobacco use for this group.¹³ Recent growth in the immigrant population, combined with the inability to reach undocumented residents, presents unique challenges to estimating tobacco use prevalence in Baltimore’s Hispanic population.¹⁵

Despite this lack of data, we expect that Baltimore City’s Hispanic young adults have a higher prevalence of tobacco use than has been documented in statewide surveys, because they are at the nexus of several risk factors for tobacco use owing to their age, socioeconomic status, and degree of acculturation. Young adults aged 18 to 24 comprise the youngest legal market for the tobacco industry and, throughout the 1990s, directed marketing to young adults via tobacco promotions in bars and nightclubs increased dramatically.^16,17 These marketing efforts have focused on the developmental transitions inherent to young adulthood, a period critical to identity formation, independence, and the establishment of health or risk behaviors that persist through adulthood.^18,19 In addition to broader marketing efforts, Hispanic young adults have been the target of tobacco industry research to determine the impact of assimilation on tobacco purchasing behavior and the subsequent marketing of tobacco products according to immigrant and acculturation status.²⁰ An example of these efforts is the development of cigarette brands “Rio” and “Dorado” designed to appeal to Hispanic markets.⁵

Several challenges make it difficult to address smoking behavior in Baltimore’s urban Hispanic young adults First, young adulthood is characterized by transitions from school to work, independent living, marriage, and parenthood; the density of demographic transitions experienced by this age group makes it is difficult to follow them longitudinally.²¹ Second, Baltimore City lacks an organized program for innercity Hispanic young adults seeking jobs, job training, and/or education, again limiting the ability to enumerate or locate this population. Third, recent or undocumented immigrants are unlikely to participate in research for fear of deportation or owing to language and cultural barriers. For these reasons, a community-based participatory research (CBPR) approach was necessary to understanding the influences on tobacco use among this unreached population.

Using CBPR to create tailored programs is particularly important for groups that are underrepresented in traditional research approaches, such as Hispanic young adults in Baltimore City. Previous studies on tobacco use in Baltimore’s urban young adults have used a community-participatory model to provide new insights on individual, environmental, and community factors that contribute to tobacco use among urban African American young adults.^22,23 The purpose of this study was to use a CBPR approach and focus group discussions to gain a better understanding of the complex array of factors that influence tobacco use in 18- to 24-year-old Hispanic young adults in Baltimore City.

METHODS

Community Partnership

The Johns Hopkins School of Public Health research team determined that partnership with a community-based organization was essential to the success of the present research, because it depended on identifying influences embedded in social and cultural structures of a marginalized population. Through previous collaboration on CBPR training, research, and service projects with the Hispanic community, the researchers had a strong working relationship with the Esperanza Center and the Latino Providers Network. The Esperanza Center has a 45-year history of providing health, legal, literacy, and other social services to immigrants in East Baltimore. The established partnership and the center’s role as a trusted and respected community resource made it an ideal partner for the present research. The Latino Providers Network has worked for the rights of Latinos in Baltimore through networking, advocacy, and education for nearly 20 years, and has served as an unofficial review board for research and service programs proposed to take place within its community.

Prior collaborations with these two partner groups have been instrumental in identifying the key health issues of concern to the Hispanic community. This ongoing dialogue enabled members of the research team to present the results of tobacco-related research with the African American community to partners in the Hispanic community, and to create a shared agenda for addressing smoking among Hispanic young adults. Key staff from the Esperanza Center participated in each stage of the research process, including the development, tailoring, and translation of informed consent documents and focus group discussion guides; identifying and recruiting eligible participants; providing a safe, familiar, and convenient location for focus groups; and reviewing and contributing to relevant presentations and manuscripts. The Esperanza Center staff also made decisions about the amount and type of the incentives to be provided and the timing of focus group sessions. The research was approved by the Committee on Human Research at The Johns Hopkins Bloomberg School of Public Health. To ensure that the community’s interests were protected and represented throughout the research, the team discussed the proposed project with and sought approval from the Latino Provider Network.

Focus Group Methodology

The research team conducted 4 focus groups with Hispanic young adults at the Esperanza Center between June and July 2008. Eligible participants were 18- to 24-year-old immigrants of Hispanic ethnicity. The initial recruitment strategy included only phone calls and in-person invitations by the Community Outreach Team at the Esperanza Center to young adults presenting themselves to the Center for services or in the client database. When this strategy failed to identify a sufficient number of eligible participants, two of the authors (JMS and ER) recruited at a local church youth group through in-person invitations. Recruitment of female participants for both the smoking and nonsmoking focus groups was particularly challenging. The Esperanza Center Community Outreach Team tried several times to bring together focus groups of female smokers to conform to the jointly developed research protocol. Each time, 2 or fewer women attended the session. In consultation with the researchers, the community partner decided a more effective approach would be to invite young Hispanic women to participate in discussions about smoking without requiring them to identify as smokers or nonsmokers a priori.

Informed consent was obtained from all participants before the start of each focus group by a bilingual researcher (JMS). The informed consent documents were in Spanish and at a moderate literacy level to facilitate understanding. Participants were given time to read the documents before the group and the facilitator provided a verbal summary of its contents. This dual and participatory process ensured that group members understood the purpose of the focus group and how the data would be used, how their identifying information would be protected and/or removed, and that they could withdraw from the discussion or leave the group at their own discretion without any penalty. Each participant received a $20 gift card to a local store selected by the Esperanza Center as a token of appreciation for their time and participation in this research. Participants were also given snacks and beverages during the sessions.

Focus groups were conducted in Spanish using a discussion guide covering 5 central thematic domains: (1) Community and social norms around tobacco use, (2) attitudes and awareness of tobacco policy/initiatives, (3) outside influences—overt and covert tobacco advertising, (4) personal attitudes and perceptions of tobacco use, and (5) individual-level factors and experiences. Each discussion was recorded, translated into English, and transcribed with only participant numbers recorded in the transcript. Each transcript was then analyzed by a single author (JMS) through repeated close readings to identify major themes under each domain. Transcripts were compared with note consistent themes across the 4 groups and ATLAS.ti software (v. 5.2) was used to organize the data as 182 non-unique quotations under 10 code families. Illustrative quotes for the major themes are presented in Table 1.

Table 1.

Conceptions of Smoking-Related Norms by 18- to 24-Year-Old Hispanic Young Adults

Influences Identified	How Influence Works	Examples Given by Participants
Gendered Cultural Norms	Expectations of Propriety for Female Behavior	“Naturally I was curious and I asked my brothers if I could try it. And my brothers would tell me that it is not right, it is not good, it doesn’t look good for a woman to smoke.” (female smoker)
	Double Standard for Acceptable Behavior for Males Versus Females	“Back home smoking is really looked down upon, something that women could not do in public, but men could.” (female nonsmoker)
	Expectations of Moral and Social Modeling by Women	“It looks bad if a girl smokes. She gives a bad example, to her kids. If you see a woman smoking and drinking, you think she’s a certain kind of woman, you think she walks the streets.” (male smoker)
Acculturation	Adoption of New Vices Post-Immigration	“People do things here that they would never have done back home. They pick up a lot of bad habits.” (female smoker)
	Decrease in Constant Oversight of Women in US Communities	“Yes, it got much worse; I never smoked in El Salvador. I came here, and now I smoke a lot.” (male smoker)
	Influence of Mainstream American Culture	“Americans … they are smoking all over the place—outside, in the bar itself—all over the place. Almost right on top of me.” (female smoker)
Brand Preference	Effect of Global Marketing	“[In El Salvador, Marlboro] is seen as the best, the most well known.” (female nonsmoker)
	Norm in Social Group	“[W]hen a bunch of friends get together it is mostly Marlboro that they are smoking.” (female smoker)
	Result of Habit	“Also, because [Marlboro] is the most popular, it’s the brand you typically start out smoking when you first try it, so you end up getting a taste for them.” (male smoker)
	Element of Racial/Ethnic Identity	“Really, I suppose the people who smoke [Newports] are Black people.” (female nonsmoker)

RESULTS

A total of 13 young men and 11 young women participated in the 4 groups, which were segregated by gender. As a result of the modified recruitment strategy, the male focus groups were segregated by smoking status, whereas the female groups were not. In the interest of maintaining participants’ trust, information on immigration status and country of origin was not collected as part of the consent process. However, most participants mentioned their home country when discussing the contrast between their culture of origin and the United States. As such, we know that the participants in the present research represent the diversity of Hispanic immigrants in Baltimore with young adults from multiple countries, including Mexico, El Salvador, Guatemala, Ecuador, and Peru. All participants had lived in Baltimore between 6 months and 5 years.

Participants identified multiple social and familial influences on Hispanic young adults’ smoking and nonsmoking behaviors. The most prominent among these were cultural identity and gender norms, which leverage substantial influence on young adults’ decisions about whether or not to smoke and how openly to acknowledge their smoking. Participants also identified immigration and the acculturation process as strong influences on smoking behaviors. These discussions revealed a strong brand preference that is a remnant of smoking norms in their home countries as well as a point that distinguishes them from other cultural groups in the United States. Each of these influences is illustrated in Table 1 and discussed in detail below.

Gendered Cultural Norms

In each of the 4 focus groups, participants identified a distinct difference between acceptable smoking behaviors for males and females. Most participants believed smoking to be an acceptable behavior for males; with some characterizing it as “macho” or “sexy.”

[A guy who smokes] looks sexy. Very macho. (female nonsmoker)

For women, however, smoking was characterized as an undesirable habit, both unfeminine and improper. These gendered social norms were consistently articulated by both men and women and smokers and nonsmokers alike, establishing a clear double standard in the normative structure for smoking among Hispanic young adults.

Speaking honestly, I think that when people see a woman smoking in our community, they think of her as a different class of person. (female nonsmoker)

Latinos don’t think that women should smoke. They think poorly of women who smoke. (female smoker)

[I]n our Latin culture, if you see a woman smoking, it’s a really bad thing. It’s vulgar. (male nonsmoker)

Acculturation

Participants also reflected on their immigration experiences in relation to their decisions about smoking. They identified changes in smoking behavior related to immigration to the United States and to exposure to American cultural norms. Many felt that smoking in general, and by women in particular, was far more widespread in the United States than in their home countries.

[In my home country] you just don’t see women smoking like you do here in the USA. (male nonsmoker)

I have a sister-in-law. She’s American though, and she smokes way too much. (female nonsmoker)

Participants noted that American cultural norms are more permissive of female smoking and of a variety of other behaviors, including alcohol consumption and drug use. Participants believe that exposure to these norms is a direct influence on the smoking behaviors of young Hispanic men and women.

People do things here that they would never have done back home. They pick up a lot of bad habits. (female smoker)

I never smoked at all, but I came here when I was very young. And when I started going to school here I picked up the habit. (male smoker)

Brand Preference

The third pattern that was consistent across groups was demonstrated by the identification of a clear brand preference among Hispanic young adult smokers. When participants were asked to name the brand that they and/or their friends smoked, the unanimous answer in all groups was “Marlboro Red.” After prompting by the facilitator, several brands were mentioned (Newport, Kool, Camel, Balmoral), but participants described these as secondary to Marlboro, which was recognized as the brand smoked most frequently by people in their peer group and by Latinos in general. Many participants attributed this brand loyalty to familiarity:

I think that Marlboro is the most smoked brand because in Mexico it is the most widely recognized. (female smoker)

Even those smokers who preferred a light or menthol cigarette also admitted that Marlboro was the cigarette of choice, and this was consistently supported by nonsmokers who reported on the preference of their smoker friends:

Marlboro Lights are smoother, and seeing as you’re smoking to relax, that’s what you’re looking for. (female smoker)

I have this friend who smokes a lot, always the same, the ones you mention [Marlboro Lights], and I asked her why she never tried anything else, and it’s like heavier, the tobacco in other makes of cigarettes … it’s just heavier. (female nonsmoker)

[I smoke Marlboro Menthol] because of the flavor. The real Marlboros are really strong and the Lights are kind of dull. (female smoker)

Stemming from CBPR with African American young adults in Baltimore, we also asked participants about the use of Black & Milds and little cigars. Unlike their African American peers, our Hispanic participants did not report use of these products.

Other Themes

In addition to these three prominent themes, participants also discussed the influence of health knowledge, marketing, and social pressure on smoking decisions.

Health Risks

There was a high level of recognition of smoking and exposure to second-hand smoke as risk factors for multiple health problems, and this was often influential in decisions not to smoke and/or to create nonsmoking areas in their homes:

Everybody knows smoking damages your health. (male nonsmoker)

I tell them that nobody is allowed to smoke in my house because of the baby. (female nonsmoker)

Peer Influence

Participants recognized that peers can leverage a great deal of influence and can use social pressure to convince a friend to smoke.

Also your friends smoke, they’re standing around, they always offer you one. It’s hard to refuse even if you don’t want one. (male smoker)

Personal responsibility

However, they also frequently expressed the view that smoking is ultimately an individual decision and responsibility. Overwhelmingly, participants did not lay blame on tobacco companies, marketing firms, peers, or older role models for young people’s decision to smoke.

You are the one who decides to smoke them. You are the one who decides to damage your health. You could be dying of lung cancer, suffering with throat cancer and it is you who decided to do it. (female smoker)

I think that smoking is bad. I think that people know that it makes them sick. They should take responsibility for themselves. (female nonsmoker)

I don’t blame tobacco companies.… They’re in it to make money. It’s their business. They survive because they make something that others want. (male smoker)

Parental Involvement and Modeling

The one exception to this emphasis on personal accountability for smoking was heard in each group, as participants discussed the importance of parental involvement and modeling. Participants believed that parents do have an important role to play in setting an example of positive behavior for their children and of preventing (early) initiation of smoking.

Because it is parents who should set their kids an example. (male nonsmoker)

Yeah, if they smoke, they have no right [to tell a child he can’t smoke], not if they smoke too. (male nonsmoker)

DISCUSSION

The four focus groups identified the same social influences as most important in the decision made by Hispanic young adults about whether or not to smoke. Although peer pressure does play a role, gendered cultural norms are far more influential in keeping women from smoking, or from openly admitting to their smoking status. Perceptions by many women of smoking as a manly and attractive behavior also levies influence on the decision young Hispanic men make to smoke. These results are consistent with previous studies that found clear differences by gender in smoking attitudes and behaviors among young people of various ethnic groups.²⁴ Similarly, the influence of immigration and facing new cultural norms in the United States affects decisions around tobacco use, often leading to increased uptake of smoking. Strong brand preference also helps to perpetuate smoking, because it contributes to a sense of shared identity and some continuity in the immigration process. Participants distinguished the brand preference of their peer group from that of other racial and ethnic groups, indicating that African American young adults smoke Newport cigarettes. Despite participants’ acknowledgement of the high price of cigarettes, cost was not mentioned as a factor influential in their smoking decisions.

Although this research yielded important findings, it was not without challenges. Chief among these was the recruitment of females who openly identified as smokers, likely a result of the cultural strictures around masculinity and femininity and that stigmatize female smokers.²⁵ The mixing of young women who admit to smoking with those who report no smoking did not seem to restrict participation or open dialogue during the discussions. It may be argued, in fact, that the female groups had richer conversations as a result of the heterogeneity of their groups, because it allowed smokers to hear the perspective of nonsmokers and vice versa. This challenge in recruitment provided a critical lesson about the importance of allowing flexibility in the research protocol to respond to the community and cultural context.

The research team also learned the importance of working closely with trusted community-based partners to identify participants for focus group discussions. Initial versions of the protocol suggested that the researchers contact potential participants. However, staff from the Esperanza Center and Latino Providers Network felt strongly that community members would be more likely to answer recruitment phone calls and accept invitations to participate if invited by a trusted service provider. Thus, all recruitment was conducted by the Esperanza Center. In addition, the team faced challenges in scheduling discussions at times that were convenient for all the participants recruited. Most of the young adults approached did not work traditional daytime hours. Many did not have consistent access to transportation, and others mentioned the difficulty in arranging child care during the session. In response to these challenges, the research team and community partner arranged to hold the sessions at the Esperanza Center, a location that was accessible to and trusted by participants. As a result, the sessions were scheduled not according to the original protocol but for mornings, evenings, or weekends, as best suited those who expressed interest in attending.

The results of this research have been discussed and shared with the local partners. This sharing of results served as the next step in the CBPR cycle, and provided an opportunity for members of the community to comment on the findings. The team at the Esperanza Center has participated in the review of posters presented at conferences and of this manuscript to ensure that the views expressed accurately reflect the community’s reality and that future work suggested is appropriate and feasible.

This study may have limited internal and external validity. Analysis by a single author may have reduced the reproducibility of the coding. Additionally, given the composition of the study sample, the findings may not be applicable to settings in which the majority of Hispanic immigrants are from Caribbean countries or from the same home country. The findings presented here also are unlikely to be representative of the experiences of young adults in the countries of origin, because the influence of the immigration experience itself shaped the social environment in which these participants face smoking decisions. However, although this research was conducted in Baltimore City, it may have some application to other urban and peri-urban contexts with large Hispanic populations.

Subsequent to the focus groups, the partners collaborated to design a second phase of research to better understand the environmental influences on smoking behaviors in the community. This consisted of a community mapping of cigarette sales outlets and observation of venues where smoking is common (i.e., bars, clubs, and lounges). These studies were carried out by participants in the focus group discussions. The results of this research will provide initial guidance for the development of culturally and contextually appropriate intervention strategies and policy recommendations to eliminate tobacco use among urban Hispanic young adults in Baltimore City. Based on this preliminary research, programs aiming to prevent or reduce smoking among Hispanic young adults should consider the strong influence of cultural norms, particularly gender-related norms and perceptions. The results of our focus groups suggest that interventions for both primary and secondary prevention of smoking should emphasize that it is an undesirable behavior for both genders and explicitly dispel some of the myths about cigarette use and brand preference as components of a macho or Latino identity. The lack of a “female smoker” focus group underscores the dissonance between smoking behavior and gender norms among Hispanic young women. To develop relevant interventions, research partnerships must also explore ways to make smoking prevention and cessation interventions relevant to Hispanic women who may be unwilling to self-identify as smokers. The experience of this research also suggests that smoking interventions aimed at Hispanic young adults would be have greater success identifying and enrolling participants if they are designed and implemented in partnership with trusted community groups.

This study also highlights the far-reaching effects of global tobacco marketing on the smoking behavior of young adult immigrants to the United States. Participants described cigarette brand preference following familiarity with the product in their countries of origin and reinforcement of brand preference through cultural, social, and racial/ethnic norms once in the United States. Tobacco control researchers, advocates, and policy makers will benefit from awareness of tobacco marketing practices in country of origin, brand preference, and the cultural associations of tobacco brand preferences when tailoring smoking prevention and cessation interventions for immigrant populations. Future research is needed to determine the most appropriate strategies for tobacco countermarketing and education addressing gender norms of smoking in this group. In the next few years, graphic warning labels will be required by the U.S. Food and Drug Administration as part of the Family Smoking Prevention and Tobacco Control Act. These labels have been shown to be more effective as a smoking deterrent among U.S. young adults than the current text-only labels and to engender different reactions from men and women.^26,27 One opportunity for research could involve developing targeted graphic cigarette warning labels with messages related to secondhand smoke and other health effects of smoking that may resonate with young Hispanic men and women.

Hispanic young adults largely view smoking behaviors and decisions as a matter of personal responsibility and choice, while at the same time acknowledging the strong influence of peers and family members. Changing the culture of smoking in this group will require continued efforts to promote tobacco-free work and home environments, programs that promote smoking prevention and cessation as the responsible and mature choice made by positive adult role models, and retargeting of tobacco control messages to address gender and cultural norms of smoking among Hispanic young adults.