Youth-Led Tobacco Prevention: Lessons Learned for Engaging Southeast Asian American Youth

Abstract

Background

Southeast Asian Americans are highly at risk for tobacco use. Youth-led, environmentally focused tobacco prevention programs have been identified as highly effective in engaging youth in tobacco research and prevention, but may be challenging for the most at-risk youths.

Objectives

We report on lessons learned in a pilot tobacco prevention program with Southeast Asian youth in Northern California.

Methods

We reviewed meeting notes, participatory research products, and a transcribed focus group with tobacco prevention project participants.

Lessons Learned

Challenges to the youths’ participation related to structural issues (limited time, scheduling conflicts, financial difficulties, aging out of programs) and personal issues (school and work pressure, family stressors). Coordinating with ongoing program activities and the county coalition enabled some supports as well as challenges.

Conclusions

Key supports for youth were youth leaders, social and financial rewards, and the ability to interpret tobacco prevention information in culturally and age-relevant media.

Youth participation in tobacco prevention programs is important in the success of these programs, especially those focused on youths. Youth-led or youth empowerment programs have shown great promise in addressing the risk factors that underlie youth tobacco use.¹ However, low-income and ethnic minority youth, who may be most at risk for tobacco use, face many challenges in committing to these activities. We describe lessons learned from a 2-year pilot project to reduce and prevent tobacco use among Southeast Asian American youth. The project is a collaboration between researchers at a nonprofit public health research center and participants and staff of Southeast Asian Young Leaders (SEAYL), a youth development program in the West Contra Costa County region of California.

Background

Contrary to the stereotype of Asian Americans as the “model minority” in the United States, high rates of smoking have been found among some Asian American groups.² Smoking among U.S. Southeast Asians has been reported at 35% to 70%.³ Refugees from rural Laos and Cambodia arrived with limited resources to establish themselves in their new country and with many challenges, including trauma-associated mental health burdens and very low literacy. Laotians and Cambodians have had the highest rates of poverty and among the lowest levels of education in California,⁴ increasing their risks for cigarette smoking.^5,6 West Contra Costa County, which includes the cities of Richmond and San Pablo, is home to one of the largest concentrations of Laotians in California, an estimated 2447 people at the time of the 2010 census. Although Contra Costa County is among the wealthiest counties in the state by per capita income, the west county communities of Richmond and San Pablo are characterized by majority non-White residents, overall low income, and pockets of extreme poverty, as characterized by data from the 2010 census, and among the highest rates of per capita violent crime in the nation.⁷

At the time of Southeast Asians’ immigration to the United States there was no tobacco control in Southeast Asia.⁸ Tobacco was a household crop, and smoking was very common.⁹ Although the children of these refugees have grown up in a society where cigarette smoking is increasingly stigmatized¹⁰ and learn about the harmful health effects of cigarette smoking in school,⁸ cigarette smoking is still highly normative.^11,12 Youth report easy access to cigarettes from friends and stores, and the common practice of “boosting” a cannabis high by smoking cigarettes increases risks for tobacco dependence.^12,13 According to the 2006 California Healthy Kids Survey, 25% of Laotian 11th graders in West Contra Costa County schools reported current cigarette use, compared with 14% of Asian youths overall, although the total number of Laotians sampled was not large enough to establish significance.

Research has shown the efficacy of participatory research programs in health promotion,^14,15 particularly in addressing health disparities.¹⁶ Full participation in research empowers communities to investigate and question the circumstances of, and undertake actions to improve, their own health and wellbeing. Empowerment is linked to positive health indicators such as self-esteem, competence, motivation, and self-efficacy,¹⁷ and individuals and communities empowered to undertake research on their own condition are better positioned to effect positive changes for themselves.¹⁸ For tobacco prevention, environmentally oriented, youth-led programs have been identified as particularly effective in engaging youth in tobacco control efforts.¹⁹ Our program focused on environmental aspects of tobacco for Southeast Asian American youth.

The project is a collaborative effort by Community Health for Asian Americans (CHAA) and the Prevention Research Center (PRC) of Pacific Institute for Research and Evaluation. CHAA is a community-based nonprofit organization serving the historically underserved Asian and Pacific Islander communities of the East San Francisco Bay Area by providing clinical services and community advocacy for mental health and substance abuse as well as within the broader frames of wellness and recovery. PRC is a nonprofit public health research institute specializing in environmental and community-based approaches to the prevention of problematic substance use. The two agencies had previously collaborated over several years on PRC-initiated research studies of tobacco, alcohol, and drug use among Southeast Asian Americans and on CHAA-initiated community-based programs to reduce drug- and gang-related violence experienced by Southeast Asian Americans. SEAYL began in 2004 as a youth advisory group attached to a community violence task force for Southeast Asians in West Contra Costa County, and has since been maintained as a youth development program of CHAA. In the current participatory action research project, SEAYL engaged in conducting primary research on the social environment for tobacco use in West Contra Costa County.

A fundamental aim of participatory health research is to engage community participants and scientists in a dialogue as co-learners, to facilitate critical consciousness of social-contextual features of community members’ lives that may impact their health so that they may be better able to take action to improve these conditions.¹⁶ Our project was designed primarily to facilitate the development of a critical awareness about the role and impact of tobacco in the individual lives of the project participants and in the life of their community. The core structure of a cycle of action and reflection, from Freirian pedagogy,^20–23 was central to our project. Throughout the 2-year period, SEAYL participants engaged in this cycle through structured research activities focusing on tobacco in their community, followed by analysis in large and small group discussions with their youth leaders and the scientific research staff, followed by more research, in an iterative process of increasing awareness and call to action. In the project, the scientific staff’s roles were to provide training and support in research concepts and methods to the participants, and to help frame the research activities within structures and guidelines that allowed the findings to be disseminated to scientists and policymakers as well as community stakeholders. The youth participants’ roles were to critically assess the impact and influence of tobacco in the lives of themselves, their peers, and their communities, and to reflect their understandings in ways that might bring about positive changes. The program was directed by co-principal investigators representing CHAA and PRC (included among the co-authors) and funding was evenly divided between the two agencies.

Methods

Elsewhere we have reported on our preliminary research findings.²⁴ In this paper, we discuss methodological strategies unique to this project as well as lessons learned.

Tobacco Project Participants and Recruitment

Prior youth-led tobacco projects in the county recommended leveraging resources in addition to curriculum and leadership to support youths’ full participation.²⁵ Funding and time constraints encouraged us to house the tobacco prevention project within the SEAYL program. SEAYL members and a team of youth leaders meet twice a week in the late afternoon at CHAA’s youth development center in Richmond. At the time that the tobacco prevention project began, one of SEAYL’s weekly meetings was dedicated to academic tutoring and mentoring and the other meeting focused on group discussion and interactive activities following a curriculum that explored a range of social justice and wellness issues including racism, sexism, health, and educational access. The group numbered 15 youth and young adults ranging in age from 15 to 22 years. SEAYL members volunteer for the program, which was at the time of our project and is to date the only publically funded youth program specific to Southeast Asian youth in Contra Costa. Many members find out about the program from friends or family members who are participants. The majority of participants (80%) were of Laotian background but also included three members of other ethnicities, including Vietnamese and African American. Approximately half of the participants were female (7 out of 15).

CHAA and PRC staff developed modules on issues related to the tobacco prevention project to include into SEAYL’s ongoing curriculum, and introduced the research project to SEAYL. Over the 2-year project period, all SEAYL participants participated in trainings on research theory and methods, Southeast Asian society, tobacco as a health and social justice issue, tobacco control policies in Contra Costa County, and political processes including mock city council meetings. Individual SEAYL members volunteered to participate in the specific tobacco research activities described below. SEAYL members received no stipends or incentives for participation in the tobacco prevention project. All research activities were approved by the research partner’s institutional review board.

Development and Implementation of the SEAYL Tobacco Project

Before the tobacco prevention program, SEAYL participants had not been actively engaged in community action research (although the CHAA Co-PI and SEAYL’s tobacco prevention coordinator and four of the young adult SEAYL members had previously participated in a tobacco prevention project that engaged a prior cohort of SEAYL members in community research on tobacco²⁶). The tobacco project allowed for the inclusion of community-based research, including community surveys, Photovoice, and community assessment.

Community Surveys

To understand the broad context of tobacco use and tobacco issues in their community, the youth developed and fielded two community surveys. The surveys included items assessing community assets in support of strengths-based organizing²⁷ as well as tobacco use and exposures. Previously, Contra Costa County successfully passed many tobacco control ordinances, with youth leadership featured in these efforts.^25,28 The county’s tobacco prevention coalition, although broad based and active, was challenged in engaging hard-to-reach sectors of the county’s diverse population, including Southeast Asian Americans. Our program staff began collaborating with coalition members. Because a focus on the coalition’s recent work had been sales of menthol cigarettes,²⁹ we included items assessing menthol cigarettes in SEAYL’s surveys. SEAYL participants input, analyzed, and interpreted these survey data.

Photovoice

In Photovoice programs, community members collect images on specified topics in photography (or video). In discussions and narrative descriptions, they use the images to assess conditions related to health disparities or other issues in their lives. The method aims to tap into participants’ experiences, thoughts, ideas, and emotions to uncover community knowledge and sometimes critically assess that knowledge to “learn anew.”²⁰ Although some Photovoice projects utilize community-generated imagery to influence policymakers, in other programs the photos aim primarily to stimulate discussion, action, and reflection among participants.³⁰ Our project utilized photography primarily to facilitate the development of SEAYL members’ critical consciousness about tobacco and their community. SEAYL participants took pictures documenting tobacco advertising, sales, and promotional items in stores and images reflecting the social environment in their own and nearby, more affluent communities, analyzed these images in discussions, and developed descriptive narratives.

Community Assessment

Youth participants conducted assessments specific to tobacco, including a survey of tobacco advertising and product availability in retail outlets. These surveys, conducted in local tobacco outlets, were often paired with Photovoice expeditions, allowing the youth participants to combine and compare “scientific” data with the qualitative and experiential evidence recorded in their photographs. Participants recorded their experiences and observations in online blogs on a tobacco research section of their private social networking website, SEAYLSpace.

Data Collection

Our efforts to document and assess the project included weekly debriefs and meetings with the tobacco prevention coordinator and the PRC researchers, monthly meetings of the SEAYL youth leaders and PRC researchers, and quarterly meetings of the community and academic co-principal investigators, during which the team reviewed and discussed the project’s process and youth responses to the trainings and activities as well as structural issues related to the project. These meetings were summarized in written notes. The tobacco project coordinator also kept written notes on these topics in weekly notes that were posted to the shared project management website. The staff and researchers accessed and reviewed participants’ blogs on SEAYLSpace (with permission) and SEAYL’s research products. These products included a PowerPoint presentation on tobacco developed by SEAYL members with the youth leaders, based on the results of their survey and Photovoice research, and a video production featuring original music and anti-smoking rap text by SEAYL members accompanying a slideshow of publically available images they sampled from internet sites (including an Asian toddler smoking a cigarette, packs of Newport cigarettes, dollar bills, cancer patients, and graphics depicting the chemical content of a cigarette).

To document the youth participants’ assessments in their own words, we conducted a focus group. The five SEAYL members who had participated in the specific tobacco research activities (community survey analysis, Photovoice, community assessment) were invited to participate in the focus group, which was held as a special session at the youth development center. These five participants were all males of Laotian descent. At the beginning of the tobacco project, female SEAYL members were already engaged in research activities on a complementary project addressing marijuana use led by a female youth leader. The focus group session was facilitated by the SEAYL tobacco prevention coordinator using a brief set of open-ended question developed in collaboration with the SEAYL youth leaders and PRC staff: “Has your participation in this project changed your views of the community?” “How do you think people in your community view tobacco?” “What are some things that you want to see different in your community, and how do you feel about your ability to make that change?” “What might make it hard for young people like yourselves to get involved with tobacco prevention?” “What do you think might motivate youth to speak up or organize around tobacco prevention?” “How do you think what you learned in the project will be useful for you in the future?” The facilitator utilized probes and follow-up questions, often based on his experiences working with the participants, to elicit detailed responses. The focus group was digitally recorded and transcribed as well as documented in written notes by a PRC researcher who attended the session.

Data Analyses

Analysis consisted of content analysis of text and primary source documents resulting from the team meetings, SEAYL research products, participant blogs and staff notes, and transcription of the participant focus group. The research staff reviewed these sources using a constant comparison approach³¹ in which themes that most saliently recurred across sources were summarized in preliminary analyses prepared as text documents. These themes are presented as lessons learned and recommendations. The CHAA program staff (SEAYL youth leaders and co-principal investigator) reviewed these findings in discussions and in draft manuscripts of the present article. When discrepancies in interpreting the findings arose, the program and scientific staff discussed these discrepancies and revised the findings until we reached agreement on the themes and discussions presented.

Lessons Learned and Recommendations

Structural Challenges

Locating the program within an existing group saved a great deal of time recruiting and training youth and staff. Critical staff capacities in youth leadership, coordination, and media production and equipment such as computers and cameras were available to the tobacco project. Importantly, SEAYL members had already developed a sense of coherence, identity, and trust among themselves and with their youth leaders, important elements in youth participatory programs.³²

However, the relationship was also challenging. The tobacco program had to be incorporated into a preexisting curriculum and accommodate to SEAYL’s organizational culture. SEAYL facilitated multiple activities, including tutoring from university students, field trips, retreats, video production, and an annual youth summit. Although participants greatly benefited from these experiences, they were sometimes distracted by these multiple activities.

SEAYL began with school-aged Southeast Asian youths, but youths who had aged out of the program were reluctant to leave because of their emotional ties and lack of other age-appropriate groups. The mixed-age group (15 to 22 years old) provided opportunities for peer learning and mentoring, but also proved challenging. Whereas older youth were interested in learning research skills that might help them in college or work, younger youth were more motivated by opportunities for creative expression. Providing various types of activities helped to overcome these challenges. One adolescent participant who professed boredom with most project activities changed his attitude after he and another youth were given the opportunity to produce an anti-tobacco video, based on their own original rap music and text. Participants reported they had learned useful skills that supported their aspirations in multiple ways:

A: If we like want to get something done, we know like the steps; we got to choose an issue and learn about it and go through the steps.

B: You got to pick a problem, then you got to see the data, then you observe. It could be useful if you want experience, if you go to college.

C: I know for my major [nursing], I’m gonna have to be y’know do a lot of research and analyzing data, so I think it’ll help me.

B: I love making videos. I would be like a music producer or something.

In line with prior studies, we recommend that program designers should aim to make the programs and activities meaningful and relevant to the lives of their youth participants.^33,34 Tobacco control can be framed in terms of larger health and social issues faced by marginalized youth. Activities should actively engage youth in their own communities and meet other needs and interests in their lives.³² Media activities such as Photovoice^35,36 and hip hop and digital music production^37,38 have been shown to be highly effective media for engaging marginalized youth in social change processes. We recommend assessing potential participants before program design, and in general advocate for youth participatory programs that are culturally and age-appropriate and youth-centered in their aims and approach.

Participants’ Life Circumstances

Marginalized youth face many challenges to participating in social change efforts.³² Some are basic needs such as food, money, and transportation. Richmond, the largest city in West Contra Costa County, has among the highest rates of violent crime of U.S. cities. For many participants, constant exposure to community violence, including the violent deaths of friends and family members, made it difficult to prioritize tobacco control. School-aged youths were trying to stay in schools; out of school youths were trying to find work or get into college. Some faced parenting at an early age. Like many children of immigrants, SEAYL youth often acted as interpreters and case managers for other family members’ health and social service issues.

I think being a young person in Richmond, it’s like almost every day is like a struggle, basically.

Most participants had no prior leadership or research experiences. Participants were hesitant to enter stores to conduct the retail survey. Some participants expressed lack of confidence in their ability to make any changes in their community. The ability and willingness of the youth leaders to encourage and support youth participants while providing them with opportunities for growth have been essential program elements. One participant summed up the group’s discussion on this point:

I guess anything is possible, but then like, in reality, I probably wouldn’t even be able to do it alone, without guidance, but y’know if I could probably get like a group of people and y’know, make a plan, anything is possible.

Program designers should anticipate that youth who are challenged in their basic needs and primary functioning will be challenged in working in tobacco prevention. Staff working with these youths must be sensitive, compassionate, and engaging. Mentoring and tutoring should be part of the work.³⁹ Staff whose backgrounds closely mirror the participants’ can understand and address the challenges these youth face in committing to tobacco control programs. Gender may also be an important consideration. Tobacco research activities for this pilot study were only conducted by male participants. SEAYL youth leaders serve as critical role models to the youth, and participants were able to work more closely with youth leaders by working on their “teams.” The “tobacco team” participants may have been as attracted to working with the tobacco prevention coordinator, who is male, as they were to working on tobacco research. Team staffing, particularly with both male and female staff members, may allow programs to attract and retain both male and female participants, as well as provide additional support for youth leaders. Our program’s holistic approach has helped to couch tobacco-related issues in the larger context of health and social issues in their community, which has broadened the appeal of tobacco research.

Additionally, we were able to coordinate the tobacco program with a summer youth employment program that provided a short but intensive period of time during which youth participants could make the project their priority. The youth blogged more on these activities and could link these activities to related topics that were discussed. The summer program enabled youth to earn money for their involvement. The overall impact of community-based and more focused activities during the summer was greater than in the usual afterschool structure.

I learned a lot about tobacco than before I worked over here. Like I didn’t know, like menthol, all cigarette have menthol in it. Then when I see people I hang out around with [smoking], I’ll be bugging them, like telling them what’s in their cigarettes and stuff.

Youth who are most at risk for tobacco use and other areas of health disparities are also highly in need of support in many other areas of their lives. Programs must provide sufficient funding to enable staff to provide that support.⁴⁰ When faced with limited funding, program designers can consider integrating tobacco prevention into existing programs. Projects should include funds for food, transportation, and social activities, which reduce obstacles and increase youth’s attachment to the program. We agree with other participatory researchers in recommending that, wherever possible, programs should provide stipends to youth participants.^39,41

Coordination With Ongoing Programs

Linking program activities with ongoing tobacco prevention efforts provided context, motivation, and tools to implement this program. However, time and effort were required to coordinate expectations and ensure that activities were culturally and age-relevant to this youth group. For example, tobacco prevention project staff provided trainings to the youth on site, and spent a good deal of time incorporating materials into their presentations related to tobacco advertising targeting Asian communities and use of menthol cigarettes and other tobacco products in these communities.

Other obstacles to coordinating efforts have proved harder to overcome. The tobacco prevention coalition has had its base of support in the more affluent eastern portion of the county, and meetings were generally held there. Because attendance constituted work for many members, coalition meetings were scheduled on weekdays during office hours. Local city council meetings were held on weekday evenings and went on until late at night. Such conditions made it difficult for west county youth to attend coalition meetings.

Despite these challenges, coordinating the summer intensive activities with ongoing tobacco control efforts was very important in increasing the youths’ awareness of tobacco-related issues. Information on the local political system in combination with their first-hand observations in their communities helped to ground tobacco research in their own lived experiences. Participants agreed that before the summer program they did not perceive tobacco as a problem for themselves and their communities and they felt that this was a barrier for other youth their age to get involved with tobacco prevention.

A: I know a lot of people that I know that smoke, they don’t really know that menthol is such a big issue, or that Richmond is like really targeted for menthol products.

B: I thought it was a really good experience for me. It really opened up my eyes about cigarettes and stuff. I learned a lot of information about all these laws about cigarettes in Richmond.

C: I was learning new information almost every time I come back here, like how to organize, and um, stuff like that. I could put it to good use, what I learned.

Providing a clearer context for tobacco prevention in their communities and a clearer understanding of its importance helped to keep these youth involved and motivated to organize around tobacco prevention. Research indicates the need to more fully involve youth in policymaking that concerns them.⁴² Alternate schedules and venues for public meetings may allow youth to attend and provide testimony at such meetings. The willingness of the county’s tobacco prevention project staff to meet youth in their own program site and within their usual meeting time is laudable and highly recommended as a means of accommodating youth as well as gaining first-hand insights into the lived experiences of these young constituents.

Conclusions

Although low-income and ethnic minority youth face challenges in committing to youth-led tobacco prevention activities, by targeting some of these challenges these youth can be successfully engaged in such programs. Appropriate funding, appropriate staffing, appropriate approach in the design stage, and accommodation to youths’ needs and life circumstances during program implementation, may enhance youths’ successful engagement. Future studies and similar collaborations should identify more ways to increase at-risk youth involvement in such programs.