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. Author manuscript; available in PMC: 2013 May 22.
Published in final edited form as: J Ethn Subst Abuse. 2013;12(1):30–50. doi: 10.1080/15332640.2013.759499

Tobacco environment for Southeast Asian American youth: Results from a participatory research project

Juliet P Lee 1, Sharon Lipperman-Kreda 2, Sang Saephan 3, Sean Kirkpatrick 4
PMCID: PMC3661407  NIHMSID: NIHMS460652  PMID: 23480210

Abstract

Despite reports of high rates of smoking among Southeast Asian refugees in the U.S., few studies have described environmental aspects of tobacco use among this population, particularly for the second generation of youths. This absence is notable, as the social environment within which second-generation youths are exposed to tobacco products differs radically from the natal environment of their parents. We describe results of a youth-led community participatory research project for Southeast Asians in Northern California. Using multiple data sources, second-generation youths documented the salience of tobacco products in their social environment, notably products such as “blunts” and mentholated cigarettes.

Introduction

Southeast Asians have been associated with some of the highest rates of smoking of U.S. populations, and reducing smoking among Southeast Asian American men was a Healthy People 2000 priority. Much of this concern is based on data collected among recent refugees during the peak of immigration (mid-1980s to mid-1990s). Very little recent research has described tobacco use, and even fewer studies attempt to describe environmental aspects of tobacco use among this population, and particularly for the second generation of youths growing up in the U.S. The absence of this information is notable, as the social environment within which second-generation youths are exposed to tobacco products differs radically from the natal environment of their refugee parents. The present study describes results of a youth-led community participatory research program for Southeast Asians in Northern California. Using multiple data sources, second-generation Southeast Asian American youths investigated the relationships between tobacco [products] and their overall social environment.

Southeast Asians in California

The Indochina wars of the 1970s resulted in mass displacement and millions of refugees from Vietnam, Laos and Cambodia. By the time of the 2000 U.S. census, far more Southeast Asians resided in California than in any other state, including Laotians (55,456 or 32% of the total 168,707) and Cambodians (70,232 or 40% of the total 171,937) (Pfeifer, 2007). Coming from agrarian backgrounds, often with little or no formal education and little or no ability to speak English, most Southeast Asian families have been dependent on public assistance since their arrival. According to the 2000 U.S. census, there were 3,854 Laotians in West Contra Costa County’s main cities of Richmond and San Pablo, comprising between 3 and 4% of these cities populations, although community leaders have proposed that many of their constituents were not included in the census due to language issues and other factors and estimate the 2000 population to be closer to 10,000. These are fairly youthful populations, with 63% under age 35, according to the census data.

Tobacco risks for Southeast Asian American youth

Tobacco use and dependence has been shown to be higher, and cessation lower, with lower socioeconomic status (Barbeau, Krieger, & Soobader, 2004; Fagan et al., 2004; Siahpush, 2006). In California, Laotians and Cambodians, along with Hmong, show the lowest socioeconomic indicators of all race/ethnic groups: 40% of Cambodians in poverty and 32% of Laotians, more than any other major racial or ethnic groups in the state, and 58% of Laotians and 56% of Cambodians 25 years and older have less than a high school education (Asian Pacific American Legal Center, 2005). Cultural traditions of normalized tobacco use, including tobacco as a household crop, derived from the rural origins of many Southeast Asians (Friis, Forouzesh, Chhim, Monga, & Sze, 2006; Jenkins et al., 1997; Moore, Lee, & Ammirati, 2010; Wiecha, Lee, & Hodgkins, 1998), together with neighborhood conditions such as social disorder, low social cohesion and lower collective efficacy (Ahern, Galea, Hubbard, & Syme, 2009; Kandula, Wen, Jacobs, & Lauderdale, 2009; Wilson, Syme, Boyce, Battistich, & Selvin, 2005), may increase the risks for smoking among these youths. Southeast Asian American youths have described primary influences on their use of tobacco, alcohol and other drugs as stress associated with the gap between their own and their parents’ generation and with poor quality of life in their neighborhoods, as well as normalized use of these substances among peers and family (Lee & Kirkpatrick, 2005).

Environmental influences on tobacco use

Environmental influences on substance use may be characterized as influences from the social and the physical environment. The impact of social influences such as peer and family practices and norms on adolescent substance use are well-established (Bauman & Ennet, 1994; Brook, Nomura, & Cohen, 1989; Kandel, 1985; Wang, 2001), including for Asian Americans (Weiss & Garbanati, 2006). Immigrant and second-generation youths may be particularly susceptible to social influences because they are actively in the process of constructing new social identities (Soller & Lee, 2010). Prior research has shown that Southeast Asian American youths are highly influenced by substance use trends modeled by co-resident African American youths (Lee, Battle, Soller, & Brandes, 2011). Many features of the physical environment that constituted influences on youth tobacco use have been curtailed by public policies—e.g. billboards, self-service sales, free distribution of tobacco products.

However, two manifestations of tobacco in the physical environment remain: tobacco advertising and the availability of tobacco products in the retail environment. Since the 1998 tobacco Master Settlement Agreement (MSA), the retail arena has become one of the few remaining channels through which tobacco companies can target both minors and those legally permitted to purchase tobacco. Since the passage of the MSA, the industry appears to have focused on increased exposures in the retail environment: research has shown increased numbers of interior and exterior tobacco advertising since the MSA (Celebucki & Diskin, 2002; Wakefield et al., 2002). The availability of tobacco products and exposures to tobacco advertising, including density of tobacco outlets and proximity to schools, are significantly associated with youth tobacco use (Henriksen et al., 2008; Henriksen, Schleicher, Feighery, & Fortmann, 2010; Novak, Reardon, Raudenbush, & Buka, 2006) including early stage (experimental) smoking (McCarthy et al., 2009). Youth are particularly responsive to tobacco advertising. Smoking initiation among adolescents has been associated with prior exposure to advertising (Biener & Siegel, 2000) including use of cigarette brands most common in their environment (Glanz, Sutton, & Arriola, 2006). Polytobacco use (concurrent use of tobacco products such as cigars and smokeless tobacco along with cigarettes) among adolescents, reported among 60% of male and 30% of females, has been associated with environmental influences including peer use, ease of access from retailers, and exposure to advertising (Bombard, Rock, Pederson, & Asman, 2008).

Southeast Asian Americans and tobacco research

Prevalence data on tobacco use, or any form of substance use, among Asian Americans are difficult to obtain and to collect. Although some, but not all, population-based datasets include “Asian” as a race/ethnic category, none include large enough numbers of specific APIA subgroups to allow for disaggregated analyses. While available data overall show low prevalence of tobacco use among Asian Americans, studies focusing on subgroups indicate many divergent patterns of tobacco use. Data collected among early groups of Southeast Asians (Vietnamese, Laotian, Cambodian) in their natal country and host countries show prevalence rates from 35–70% (Levin, Nachampassack, & Xiong, 1988; Rumbaut, 1989; World Health Organization, 2003). Lung cancer rates among some of these groups have been identified as 16% higher than among white Americans (Coultas et al., 1994). Smoking may be reduced over time in the U.S. among adult men (Jenkins, McPhee, Ha, Nam, & Chen, 1995; Wiecha, 1996), and a recent study of Southeast Asian Americans indicated that 24.7% of men were former smokers (Constantine et al., 2010), but time in the U.S. may elevate smoking among women (An, Cochran, Mays, & McCarthy, 2008; Constantine et al., 2010). Very little data is available on smoking among second-generation Southeast Asian youths. According to the 2006 California Healthy Kids Survey of in-school youth, 25% of Laotian 11th graders in West Contra Costa County reported current cigarette use, compared to 14% of Asian youths overall; however, the total number of Laotians sampled was not large enough to establish significance. Although a previous study indicated that Southeast Asian Americans may be aware of and responsive to federal and state tobacco control policies (Battle, Lee, & Antin, 2010), prior to the current project there were no published reports documenting Southeast Asian Americans’ exposure to tobacco products in the local retail environment.

Southeast Asian Young Leaders (SEAYL)

SEAYL formed in 2003 as a youth advisory group attached to a local coalition of health and social service agencies focusing on coordinating services for West Contra Costa County Southeast Asian youths and families. SEAYL, now a program of Community Health for Asian Americans, involves primarily Laotian youths, both male and female, but includes participants of other (including mixed) ethnicities as well, e.g. Vietnamese, Latino and African American. The group of 15 members, aged 15 to 26, meets weekly with three youth leaders. SEAYL organizes an annual youth summit attended by 200–300 youth and adults each year, and has been involved in many other community events and planning efforts. Prior youth-led tobacco programs in the county recommended leveraging resources in addition to curriculum and leadership to support youths’ full participation (Reed, Dennis, Dickson, DuBrow, & Freestone, 2001). For these reasons we chose to house the project within SEAYL.

Tobacco prevention efforts in West Contra Costa County

In 1990 Contra Costa County established a Tobacco Prevention Project under the Department of Public Health. The efforts of the program and affiliated county Tobacco Prevention Coalition have included the passage of ordinances to reduce exposure to secondhand smoke, reduce access to tobacco products and counter pro-tobacco influences. In late 1998, after two years of intensive community education and organizing work, the Contra Costa Board of Supervisors adopted what was at the time one of the most comprehensive tobacco control ordinances in the country, the Tobacco-Free Youth Ordinance. The ordinance restricted tobacco advertising in close proximity to schools and playgrounds, as well as sales of promotional items and self-service tobacco sales, and tobacco control advocates have been working since to ensure the passage and enforcement of the policy in cities throughout the county (Pratt, Dickson, Freestone, & Dennis, 2000). A youth mobilization component provided a vehicle for youth involvement in this policy work, with a focus on billboard advertising in West Contra Costa County (Reed et al., 2001). The city of Richmond has adopted comprehensive secondhand smoke ordinances, tobacco licensing ordinances, smoke-free pharmacies, and restrictions on sampling tobacco products. A Richmond city ordinance restricts the amount of allowable storefront signage to no more than 25% of any single windowpane and no more than 10% of all window space (Contra Costa County Tobacco Prevention Project, 2010). These efforts have been lauded by tobacco control advocates (Bartos, 2010).

Methods

The study was guided by two overarching approaches to tobacco research:

The environmental approach aims to alter the existing structures of community systems associated with specific substances. Rather than directly address individual health behaviors (e.g. smoking), the environmental approach involves community-based prevention programs that seek to effect change at the community or population level and to affect specific social-environmental interactions that underlie substance use and abuse, and in this way seek to alter the individual (potential) user’s relationships to their physical, political, economic and social environments (Gruenewald, Treno, Holder, & LaScala, In Press). Environmental approaches target policy makers rather than individual community members, and mobilize community members in support of program goals rather than attempt to alter community members’ individual behaviors (Treno & Lee, 2002).

The participatory approach

Research has shown the efficacy of participatory research, or empowerment, programs in health promotion (Israel, Checkoway, Schulz, & Zimmerman, 1994; Maton, 2008), particularly in addressing health disparities (Wallerstein & Duran, 2006). Empowerment is linked to positive health indicators such as self-esteem, competence, motivation and self-efficacy (Marr-Lyon, Young, & Quintero, 2004), and individuals and communities empowered to undertake research on their own condition are better positioned to effect positive changes for themselves (Holden, Messeri, Evans, Crankshaw, & Ben-Davies, 2004). Youth-led tobacco prevention programs oriented to environmental approaches have been identified as effective in engaging youth in tobacco control efforts and changing their awareness of tobacco (Hinnant, Nimsch, & Stone-Wiggins, 2004). These programs may result in increased sense of efficacy as well as reduced smoking among youth participants (Winkleby et al., 2004).

Project components

Our two-year project was a collaborative effort between SEAYL and scientists from the research partner agency. Prior to this project, very few members of SEAYL had previously engaged in action-oriented community research. The tobacco project allowed for the inclusion of community-based research including a guest speaker series, to introduce tobacco as a multi-dimensional issue for individuals and communities; community surveys to assess the broader context of tobacco use and tobacco issues in their community as well as community assets; a PhotoVoice project to engage the youth in documenting and reflecting on their social and physical environment; and a tobacco outlet survey to engage the youths in documenting and reflecting on the presence of tobacco in their community. In these trainings and activities, the scientific and program staff worked closely with SEAYL participants and with local tobacco control advocates to identify research issues; develop and field data collection instruments; analyze results of both quantitative and qualitative data collection; and develop a plan for a community intervention to reduce and prevent tobacco use among Southeast Asian Americans. We have described many of the lessons learned from this pilot study in a manuscript (Lee, Lipperman-Kreda, Kirkpatrick, & Saephan, 2012). Here we present the results of our collaborative community research. All research activities were approved by the research agency’s Institutional Review Board.

Data collection and analysis

Community and tobacco surveys

In the first project year, SEAYL conducted a community survey at their annual youth summit. For this survey the youths collected data from a convenience sample of youths and adults attending the annual youth summit organized by SEAYL. In order to collect data more specifically on tobacco use, in the second project year SEAYL conducted a community survey that aimed to identify smokers. For this survey SEAYL participants recruited a convenience sample totaling 73 West Contra Costa County community members. Many respondents were recruited at or near tobacco outlets; others were recruited from among the friends and family members of the youth participants. This tobacco survey included items about cigarette smoking behaviors including smoking of menthol cigarettes and items about tobacco advertising in the retail environment for those community members. Both surveys were self-administered paper forms developed by the youth participants in collaboration with the research staff using example items from various national surveys. The surveys were voluntary and anonymous and, due to limited funds, respondents were not compensated for completing the surveys. The youth were trained how to distribute the surveys as well as how to input and conduct preliminary analyses of the data in SPSS and how to interpret the results.

Store observations

SEAYL participants conducted observations at 25 stores that sold tobacco products in Richmond, California. Retail outlets were selected as follows. The youth leaders and participants generated a list of stores in the vicinity of their schools, homes and the project office located on a main business thoroughfare near Richmond’s city center. The youths then attempted to conduct an observation in all of these tobacco outlets. On a paper form which they filled in outside the outlets, they recorded how much (percent) and what kinds of tobacco ads were visible inside and outside stores, presence of promotional items and tobacco within access to patrons (self-service) and of signs. Items for the store observations were developed in coordination with the Contra Costa County Tobacco Prevention Project, and the youth were trained to conduct these observations and record the results. The youth participants conducted these observations in pairs or small groups, accompanied by a youth leader from the program staff. As with the community surveys, SEAYL participants input and analyzed the resulting data.

PhotoVoice

Media activities such as PhotoVoice (Gant et al., 2009; Wilson et al., 2007) have been shown to be highly effective for engaging marginalized youth in social change processes. PhotoVoice is used in participatory research to enable community members to focus their observations on their own lived experiences. Community members collect images on specified topics in photographs (or video) and use the images as objects for discussions and development of narrative descriptions assessing conditions related to health disparities, to identify and describe root causes or to connect issues in their lives revealed through the images. Narratives are sometimes from a situated point of view, in the voice of the photographer/videographer, or are the product of a group narrative development process. For SEAYL’s PhotoVoice projects, staff accompanied youth participants to various Richmond neighborhoods to collect images of these communities. The first outing was focused specifically on “smoke shops,” retail outlets dedicated to smoking products and paraphernalia. The youth took pictures of the storefronts and were given permission to take photos inside of some of the shops as well. A second outing aimed to document through photography the differences between youth-identified healthy, positive neighborhoods and unhealthy poor neighborhoods. Following these outings, the photographers selected from among dozens of photos, presented these images to the group and discussed their observations of the process and the resulting images. The participants then developed brief descriptions to accompany selected images.

Results

Tobacco outlet survey results

Data from inside store observations showed no accessible tobacco, but promotional items were observed in 26% of stores. Tobacco ads were observed in nearly all stores (93%), and most stores (78%) advertised menthol cigarettes. Data from outside store observations showed that most stores (78%) advertised tobacco products outside (and most had more than one advertisement). Of these, nearly all (85%) advertised menthol cigarettes. Of all stores, 44% had more than 10% of outside window space covered with ads, in violation of the city signage ordinance.

Community survey results

Respondents were 93 youth and adults from West Contra Costa County recruited from persons attending the annual SEAYL youth summit (survey respondents from other communities were eliminated from the present analyses). Of these respondents, 79.6% were under age 18; 44.1% were female; and 67.6% reported being uninsured or insured by MediCal or MediCare. In terms of race/ethnicity 60.2% reported their ethnicity as Asian/Pacific Islander, 23.7% African American, 15.1% Latino, and 4.3% white. Of all 93 respondents, 57% were from the city of Richmond. Respondents in this survey reported low use of cigarettes but high availability of and exposure to tobacco products. For lifetime cigarette use 28.4% of respondents answering this question (n=81) reported any lifetime smoking; for those reporting on past 30 days’ use (n=78), 11.5% reported any current smoking. Of those responding to an item on ease of access to cigarettes in their neighborhood (n=81), 58% reported it was easy or very easy to get cigarettes. Items on use of or exposure to mentholated cigarettes were not included in this survey. Recruitment for this survey was not difficult as respondents were recruited at SEAYL’s youth summit and possibly represent a highly service-oriented group; however, tobacco use among this population may not represent the larger community.

Tobacco survey results

This survey aimed to collect information from persons more directly involved in tobacco use. The results of this survey indicated high exposure to mentholated cigarettes for West Contra Costa County residents. Of the 73 respondents, 18% were youth (under age 18), 34% young adults (18–24) and 45% were adults (25 and over). Of these respondents, 62% of youth, 64% young adults and 67% of adults smoked at least once in their lives, and 53% of youth, 48% of young adults and 53% of adults reported smoking in the past 30 days. Among youth 46% reported that they usually smoked menthol cigarettes. In terms of exposure to tobacco use by others, 85% of youth, 60% of young adults and 64% of adults reported that people around them usually smoke menthol cigarettes. In terms of exposure to tobacco advertising, 60% of youth reported usually seeing tobacco ads when they go to a convenience store and 50% of youth reported seeing Newport ads the most. The youth participants reported that recruitment for this survey, whether near tobacco outlets or among friends and family members, was difficult because the project budget did not allow for the provision of incentives, and refusal rates (although not documented) were reportedly high.

PhotoVoice results

In subsequent discussions and in written narratives accompanying their images, the youth found that the majority of tobacco-related products were targeted towards youth. Their photographs and narratives documented exposures to mentholated tobacco products within retail environments appealing to youths (see Figure 1) as well as other tobacco products marketed to youths, including “blunts” (small cheap cigars often used for smoking marijuana) and blunt wrappers (see Figure 2). The two examples presented here illustrate the results of the PhotoVoice component.

Figure 1. Shopping for Clothes.

Figure 1

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Kids go buy clothes from these smoke shops all the time (photograph and caption by Daniel Phan).

Figure 2. Is this the candy section?

Figure 2

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My little brother saw this and thought it was candy. He cried when I didn’t buy him anything (photograph and caption by Daniel Phan).

Discussion

Guided by two approaches to tobacco research, the environmental approach and the participatory research approach, the current study presents data collected by Southeast Asian American youth about their exposure to tobacco in the retail environment in their community. Utilizing several types of data collection allowed the youth participants to assess a range of ways in which they are exposed to tobacco products, including use by people around them as well as advertising and product availability. While the findings from the community and tobacco survey cannot be said to represent all Southeast Asians in the community, nevertheless the process of conceiving, conducting and analyzing the survey results raised the youth participants’ awareness of tobacco products and tobacco use in their environment. This awareness shaped their approach to the store survey and PhotoVoice components of the project. Overall, the youth identified problematic environmental exposure to tobacco products and advertising for Southeast Asian American youths. In particular they identified high exposure to products marketed to youth and ethnic minorities, including mentholated cigarettes and blunts and blunt wrappers. These findings indicate the limitations of current policies and programs aimed at protecting youth from the negative effects of tobacco use including exposure to tobacco in their environment.

Disparate impacts of tobacco control policies

Although federal, state and local policies aimed at regulating and restricting tobacco use and sales are intended to protect all members of these communities equally, there is evidence that these policies may have disparate impacts on disparate populations (Moore, Annechino, & Lee, 2009; Moore, Lee, Antin, & Martin, 2006; Moore, McLellan, Tauras, & Fagan, 2009; Tauras, 2007). Regulatory policies that aim to reduce tobacco use by raising the costs of smoking may disproportionately impact ethnic minority smokers (Tauras, 2007). Policies aimed at restricting sales of tobacco products have also been shown to be unevenly enforced in some locales. Low income and ethnic minority communities have been associated with weaker enforcement of laws restricting underage tobacco sales (Lipton, Banerjee, Levy, Manzanilla, & Cochrane, 2008). Enforcement of tobacco control policies may be tasked to any of a number of agents (health inspectors, police officers, fire marshals) depending on local structures and circumstances, and may be only one of many tasks assigned to these enforcement agencies (Satterlund, Lee, Moore, & Antin, 2009). Community mobilization and advocacy are critical in raising the priority of such policies for enforcement officials (Treno, Gruenewald, Lee, & Remer, 2007; Treno & Lee, 2002), and in the establishment of new policies to extend protections (Rogers, Feighery, Tencati, & Butler, 1995). However, the populations who may be most impacted by the presence and availability of tobacco may be least able to mobilize the community effort needed to ensure the enactment and enforcement of these policies in their communities. Asian/Pacific Islander American communities have been identified with lower levels of capacity to launch and sustain tobacco control efforts (Lew, Tanjasiri, Kagawa-Singer, & Yu, 2001), including in California (Tanjasiri, 2001).

Targeted marketing

Much research, including reviews of tobacco industry documents, has established the strategies used by the tobacco and alcohol industries to target their products to specific populations. Targeted marketing in part reflects standard business practices of identifying and exploiting new markets. The practice has serious consequences on the health of these populations when these products are alcohol and tobacco. The practice of targeting low-income communities and communities of color, including Asian Americans, and targeting of youth for advertising and distribution of these products is well-documented (Feighery, Ribisl, Schleicher, Lee, & Halvorson, 2001; Henriksen, Feighery, Schleicher, Haladjian, & Fortmann, 2004; Moore, Williams, & Qualls, 1996; Muggli, Pollay, Lew, & Joseph, 2002). Low income and ethnic minority status have been associated with density of tobacco outlets (Reid, Peterson, Lowe, & Hughey, 2005a; Schneider, Reid, Peterson, Lowe, & Hughey, 2005; Siahpush, Jones, Singh, Timsina, & Martin, 2010; Yu, Peterson, Sheffer, Reid, & Schnieder, 2010) and proximity of outlets to schools (Ogneva-Himmelberger, 2010). The relationship between outlet density and cigarette use may be stronger in ethnic minority communities (Peterson, Lowe, & Reid, 2005; Reid, Peterson, Lowe, & Hughey, 2005b).

In addition to tobacco outlet density and proximity to schools, low income/minority communities have been associated with larger exterior tobacco advertisement and with ads offering lower prices and more likely to advertise mentholated cigarettes (Seidenberg, Caughey, Rees, & Connolly, 2010). Targeted marketing also includes strategies to increase sales of specific products by specific populations. The targeting of mentholated cigarettes to specific populations including African Americans, women and youths is evidenced both by investigations of tobacco industry documents (Gardiner, 2004; Sutton & Robinson, 2004), and by the higher rates of use of these products within these populations (Clark, Gardiner, Djordjevic, Leischow, & Robinson, 2004; Giovino et al., 2004). Although not significantly preferred among adult Asian Americans (Trinidad, Perez-Stable, Messer, White, & Pierce, 2010), among Asian American high school smokers, 60% reported preferring mentholated cigarettes (Appleyard, Messeri, & Haviland, 2001). It is unclear whether tobacco companies have deliberately targeted Asian Americans (Sutton & Robinson, 2004). However, a study of tobacco outlets in Hawaii found that menthol brands were the most heavily advertised cigarettes (Glanz et al., 2006). Other tobacco products may also be targeted to ethnic minorities and youths including cigarillos and small cigars (Singer et al., 2007), particularly those used to roll marijuana (blunts), and cigar leaves used for the same purpose (blunt wrappers) (Sifaneck, Johnson, & Dunlap, 2005). Cigar use continues to rise among young adults (Delnevo, 2006). Blunt smoking has been shown to be associated with youth, particularly young adults, and with ethnic minority and low socio-economic statuses (Golub, Johnson, & Dunlap, 2005; Ream, Johnson, Sifaneck, & Dunlap, 2006). Features of blunts, blunt wrappers and small cigars and cigarillos including packaging and flavoring as well as low cost (Department of Health and Human Services Office of Inspector General, 1999; Page & Evans, 2003) indicate that these products may be targeted to youth.

Increased risks for disparate populations

Targeted marketing to disparate populations means that these populations are not only at increased risk for use of these tobacco products and suffering the harmful effects of tobacco use, but also for other risks associated with these products. Use of mentholated cigarettes by adolescents increases the risk of nicotine dependence (Hersey et al., 2004) and is associated with lower rates of success in quitting among ethnic minority groups (Trinidad et al., 2010). Smoking menthol cigarettes may result in equivalent or increased effects, including nicotine dependence, compared to non-menthol users (Fagan et al., 2010; Hersey et al., 2004). Tobacco makers have been found to strategically calibrate the amount of menthol flavoring used in order to increase the appeal of these products to youthful smokers (Kreslake, Wayne, Alpert, Koh, & Connolly, 2008). Similarly, small cigars and cigarillos, with higher nicotine levels than cigarettes, may increase the risks for users, who additionally may not recognize these items as containing nicotine or even as tobacco products (Page & Evans, 2003; Singer et al., 2007; Yerger, Pearson, & Malone, 2001). Teens have reported easy access to these products at convenience stores and gas stations (Department of Health and Human Services Office of Inspector General, 1999). Blunts smoking may increase the risks for use of other forms of marijuana and for smoking cigarettes for Southeast Asian youths and young adults (Lee, Battle, Lipton, & Soller, 2010) and has been associated with increased dependence on cannabis and on tobacco (Ream, Benoit, Johnson, & Dunlap, 2008; Timberlake, 2009). The practice of smoking a cigarette after marijuana to enhance a marijuana high, known as “boosting” or “chasing,” has been associated with marijuana smoked in blunts (Ream et al., 2008; Sifaneck et al., 2005) including specifically for Southeast Asian American youths (Lipperman-Kreda & Lee, 2011). Among African Americans adolescent smokers, menthol cigarette use is reported more commonly among those who had ever used blunts (Giovino et al., 2004). Document review shows the tobacco industry has been aware, since the 1970s, of a connection between menthol cigarettes and marijuana smoking, particularly by marijuana smokers seeking to prolong or intensify their high (Sutton & Robinson, 2004).

Our findings lend support to current calls for more stringent regulation of tobacco products. At present, mentholated cigarettes are not included in a federal ban on flavored cigarettes, nor are other tobacco products such as cigars, cigarillos and blunt wrappers (United States Congress, 2009). In December 2010 the Contra Costa County Board of Supervisors passed a resolution urging the Food and Drug Administration to ban menthol in cigarettes (Contra Costa County Board of Supervisors, 2010). More recently, the cities of Richmond and San Pablo, California, have passed their own separate resolutions regarding a ban on mentholated cigarettes.

Conclusions

The present study indicates that exposure to tobacco products, and in particular those products heavily marketed to youth and ethnic minorities, are highly salient and pervasive within the social environment of the Southeast Asian American youths in our project. The results presented here do not provide evidence that tobacco producers and retailers are specifically targeting Southeast Asian Americans, similar to the overt campaigns by marketers to attract African Americans to their products. However, because many Southeast Asian refugee families find themselves living in neighborhoods with high proportions of African American residents, they and their children are exposed to the same retail environment in which products such as blunts, blunt wrappers and mentholated cigarettes are highly salient. Limitations of data collection in the present study (e.g. convenience samples) did not allow us to link these exposures to use of these products among Southeast Asian youths. However, the participants in our programs themselves identified these products as problematic influences for smoking among their families and peers. The study indicates the need for attention to environmental exposures in tobacco prevention programs aimed at Southeast Asian Americans. Additionally, the study indicates the need for up-to-date prevalence data on the use of tobacco products, and specifically those products marketed to youth and ethnic minorities, among this at-risk subpopulation. The findings may additionally indicate a need for tobacco research and prevention efforts focused on immigrant and refugee groups to include the local retail environment when considering social-environmental influences on tobacco uptake and maintenance among these populations.

Acknowledgments

Photographs and captions by Daniel Phan. The research and preparation of this manuscript were made possible by a grant from the University of California Office of the President’s Tobacco-Related Disease Research Program (TRDRP #18BT-0044, Co-P.I.s Juliet Lee and Sean Kirkpatrick). The authors wish to acknowledge the members of SEAYL, in particular Daniel Phan, Mory Saengsourith, Alex Douangdara, Anthony Phongboupha and Bryan Phuthama for their work related to tobacco prevention; and SEAYL staff members Adel Hazan, Zelda Coleman, John Abella and Sue Denny. We thank members of the Contra Costa Tobacco Prevention Project for their help and support.

Contributor Information

Juliet P. Lee, Prevention Research Center, Pacific Institute for Research and Evaluation, Berkeley, CA

Sharon Lipperman-Kreda, Prevention Research Center, Pacific Institute for Research and Evaluation, Berkeley, CA.

Sang Saephan, Community Health for Asian Americans, Oakland, Richmond and Antioch, CA.

Sean Kirkpatrick, Community Health for Asian Americans, Oakland, Richmond and Antioch, CA.

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