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Published in final edited form as: Addict Behav. 2014 Jul 10;39(12):1874–1878. doi: 10.1016/j.addbeh.2014.07.003

A Comparison of Cambodian-American Adolescent Substance Use Behavior to National and Local Norms

Eric R Pedersen 1, Grant N Marshall 1, Terry L Schell 1, Eunice C Wong 1, S Megan Berthold 1,2, Katrin Hambarsoomian 1
PMCID: PMC4164569  NIHMSID: NIHMS612944  PMID: 25128638

Abstract

This study was designed to compare rates of alcohol, marijuana, and cigarette use in Cambodian-American adolescents with norms from nationally- and regionally-representative peers. Substance use data from 439 10th grade Cambodian-American adolescents in Long Beach, California were compared to grade- and gender-matched nationally representative data from the Monitoring the Future study and data from the California Healthy Kids Survey of students within the same school district. Overall, the Cambodian-American youth were less likely than nationally- and regionally-representative youth to use alcohol, marijuana, and cigarettes. Specifically, relative to estimates obtained for the general population and students attending school in the same school district, Cambodian-American youth were significantly less likely to use alcohol and marijuana. Cambodian-American youth were also less likely than youth in the general population to smoke cigarettes, but did not differ statistically from youth within their same school district. As a group, Cambodian-American youth may not be at especially high risk for substance use. As is the case with virtually all populations, some individuals within the Cambodian-American group are likely to have more difficulty than others with substance use concerns. Thus, additional research is needed to identify factors that might help to identify high users with potential service needs.

Keywords: substance use, Cambodian-American, youth, adolescents

1. Introduction

Asian-Americans are the fastest growing segment of the United States (U.S.) population (U.S. Census Bureau, 2012) and are underrepresented in psychiatric epidemiological research (Sue et al., 2012). Moreover, Asian-Americans are particularly understudied with respect to substance misuse (Caetano et al., 1998; Fang et al., 2011; Harachi et al., 2001; Sue et al., 1995). Thus, there is an emerging need to gather information regarding the health and risk behavior of individuals from specific Asian-American subgroups. The current investigation examined the substance use behavior of one of these Asian-American subgroups, the children of Cambodian refugees, who are believed by some to be at high risk for substance use given the social history of their parents (Lee et al., 2008; Makimoto, 1998; Rumbaut, 1989).

Cambodian-American youth represent an important subgroup for examination due to the stressors and mental health problems prominent among their parents. Research suggests that children of parents from disadvantaged groups and children of parents with mental health problems are at-risk for mental health problems including substance misuse (Hancock et al., 2013; Huntsman, 2008; Lacey et al., 2011; Luthar & Sexton, 2007; Poulton et al., 2002). Cambodian refugees immigrated in large numbers to the U.S. following the brutal and traumatic reign of the Khmer Rouge; during which 22–25% of an estimated Cambodian population of 7.8 million had lost their lives (Kiernan, 1993; 2003). Many surviving Cambodian refugees suffer from long-standing Posttraumatic Stress Disorder and Major Depression, stemming from their high trauma exposure (Carson and Rosser-Hogan, 1993; Marshall et al., 2005). In reaction to these stressors and diagnoses, Cambodian refugees have traditionally been believed to suffer from high rates of substance use and related problems (D'Avanzo, 1997; D'Avanzo et al., 1994; Ma et al. 2002; Makimoto, 1998; Wewers et al., 1995), often attributed to coping-related reactions to trauma, difficulties adapting to life in the U.S., feelings of marginalization from American society, and greater accessibility of alcohol in the U.S. than in Cambodia (Amodeo et al., 1997; D'Avanzo, 1997; Makimoto, 1998).

However, there is a mix of evidence regarding the substance use behavior of Cambodian refugees and their children. More recent work indicates that Cambodian refugees do not engage in drinking behavior at high levels (D’Amico et al., 2007) and premigration trauma does not associate with alcohol use disorders in the refugee population (Marshall et al., 2005). In particular, we found that of nearly 500 Cambodian refugee participants, nearly three-quarters reported no drinking behavior in the past month and only 4% met criteria for an alcohol use disorder (D’Amico et al., 2007; Marshall et al., 2005). The research for Cambodian adolescents is also mixed; with some studies citing elevated risk (e.g., Lee et al., 2008; 2010) and others suggesting use may be no more problematic among this group than among others (Lim et al., 2011).

Given a mix of evidence regarding substance use risk in the Cambodian-American population, this study was designed to examine the substance use behavior of Cambodian-American youth (i.e., children of Cambodian refugees) to determine if they are an at-risk subgroup of the American population. The available research on substance use of Cambodian-American youths is limited in several respects. First, relatively little research has addressed the issue. In addition, much of the available literature consists of studies based on small nonrepresentative samples. Studies combine substances in analyses and aggregate across youths from other Southeast Asian countries and across gender. These analytic strategies may obscur important differences between groups or substances (e.g., Lee et al., 2008; Lee et al., 2010; Lim et al. 2011). For example, studies report high cigarette, marijuana, and alcohol prevalence for Southeast Asian youth, but these studies combine several ethnic groups into a heterogenous category (e.g., Cambodian, Mien, Lao) and employ a snowball sampling recruitment strategy in which heavy using participants recruit others within heavy drug-using environments, potentially biasing the sample (Lee & Kirkpatrick, 2005; Lipperman-Kreda & Lee, 2011).

In addition, investigations often fail to differentiate American-born children of Cambodian refugees from their Cambodian-born counterparts who immigrated as refugees. Cambodian refugee children who experienced first-hand the atrocities of the Khmer Rouge period and/or traumas experienced in refugee camps may display disparate substance use profiles than U.S.-born children of Cambodian refugees; the latter group of which very little is known (Lee & Kirkpatrick, 2005; Mollica et al., 1997; Morgan et al., 1984). Finally, insofar as a substantial portion of the studies on both youth and adults are over 15 years old, it is important that the knowledge base include a picture of the current status of Cambodian-American youth.

1.1 Present Study

In the present study, we provide estimates of the alcohol, marijuana, and cigarette use behavior of a relatively large sample of second-generation Cambodian-American adolescents. We compared data collected from 10th grade Cambodian-American students attending high school in Long Beach, California to grade- and gender-matched available nationally representative data from the Monitoring the Future (MTF) study. MTF is a large and representative dataset containing substance use behavior for adolescents and young adults from over 400 urban, suburban, and rural U.S. schools. In addition, We compared our sample to a grade- and gender-matched sample of youth from the CHKS within the same school district of our sample The California Healthy Kids Survey (CHKS) is a California school-based study that has data on substance use behavior of youth in all California school districts.

2. Method

2.1 Participants

Four-hundred and thirty-nine Cambodian-American adolescents participated in the Cambodian-American Adolescent Survey (CAAS), a larger study designed to examine the health and risk behavior of children of Cambodian refugees in Long Beach, California. The sample consisted of 10th grade students enrolled in the Long Beach Unified School District (LBUSD) in the years 2009–2011. The LBUSD is the primary K-12 education system for students residing in the largest Cambodian refugee community in the U.S. (Quintiliani & Needham, 2008). Contact information for all households with self-assessed Cambodian ancestry was obtained from the LBUSD under the Family Educational Rights and Privacy Act. Letters describing the study in both English and Khmer were mailed to a random subset of all Cambodian heritage households in the school district. Persons eligible to participate were American-born students who were living with a biological mother who emigrated to the U.S. as a refugee. If a biological mother was not living in the household, then biological fathers were interviewed (N = 19). Home visits were then conducted to screen for eligibility and obtain consent from parents. After obtaining parental consent, separate home visits were made to obtain assent and interview each child. We had an overall youth response rate of 78.4%, as determined by Formula 3 of the American Association for Public Opinion Research (AAPOR, 2011). Data were collected between June 2011 and July 2012. Fifty-one percent of the sample was female. Participants reported a mean age of 16.28 (SD = 0.52).

2.2 Procedure

The youth interview team consisted of Cambodian-American lay interviewers. Interviewers received extensive training before conducting interviews as well as active supervision throughout the study period. Data were obtained via face-to-face, fully structured, computer-assisted interviews that took place in participants’ homes. All youths expressed a preference to complete interviews in English and interviews took 60 minutes on average to complete. Following the interview, participating youths received $25. The RAND Institutional Review Board approved and monitored the study.

2.2.1 Measures

Participants completed measures of substance use based on the items utilized in the MTF studies (Johnson et al., 2012). In particular, participants were asked to indicate if they had ever used alcohol (yes/no), marijuana (how many occasions in lifetime; 1 = 0 occasions to 7 = 40 or more times), and cigarettes (1 = never to 5 regularly now). Participants reported on past 30 day use of alcohol and marijuana (1 = 0 occasions to 7 = 40 or more times), as well as cigarettes in the past 30 days (1 = not at all to 7 two packs or more per day) and heavy drinking (how many times have you had five or more drinks in a row; 1 = none to 6 = 10 or more times) in the past two weeks. All items were dichotomized for analyses (i.e., used in lifetime, used in past 30 days, used in past two weeks). The MTF items used for analyses matched those from the CAAS. Response options for items on the CHKS varied slightly from CAAS and MTF items; however, items were able to be clearly dichotomized to examine “use” versus “non-use.” Heavy drinking (called “binge drinking” on all three surveys), was assessed with respect to the past two weeks in the CAAS and the MTF. In contrast, heavy drinking was assessed with regard to the past 30 days in the CHKS. Thus, we were unable to compare CAAS and CHKS rates for this item.

2.2.2 Analysis

Prevalence of any lifetime and past 30 day use of alcohol, marijuana, and cigarettes and episodes of heavy drinking over the past two weeks for the CAAS sample were compared to two reference populations: (1) a nationally representative sample of N=15,330 10th grade students from the 2011 MTF (Johnston et al., 2011) and (2) a representative sample of 9th and 11th grade students in the LBUSD from the 2010–2011 CHKS (WestEd, 2011). Data analyses compared overall prevalence rates as well as gender-specific rates across the three samples using chi-square tests. CHKS surveys for the LBUSD were only distributed in 9th (N = 847) and 11th grades (N = 846). Thus, we took the average rates of the 9th and 11th grade subsamples from the CHKS when comparing to the CAAS 10th grade sample.

3. Results

3.1 Alcohol Use

Table 1 contains prevalence rates for each substance for the total samples as well as for male and female subgroups. Alcohol use was lower among Cambodian-American youth relative to those in both the MTF and CHKS samples. In particular, Cambodian American adolescents had a significantly lower prevalence of lifetime drinking (36.45%) and past 30-day drinking (20.50%) relative to either other U.S. 10th graders (56.10% for lifetime, 27.80% for past 30 days) or their peers in the same school district (54.00% for lifetime, 28.00% for past 30 days). In addition, the Cambodian-American adolescents had lower rates of past two week heavy drinking relative to the other U.S.10th graders (11.39% versus 15.30%). A similar pattern of results was found when the samples were stratified by gender. However, while overall heavy drinking rates for Cambodian-American youth were statistically different from other U.S. 10th graders, these differences were not evident for males and females specifically. Additionally, while past 30 day drinking was significantly lower overall among Cambodian-American youth compared to the their peers in the same school district, this difference was evident for females only.

Table 1.

Prevalence rates and chi-square comparisons of substance use behaviors among the three samples

Alcohol Marijuana Cigarettes
Lifetime Past 30 days Past two weeks
heavy drinking1 		Lifetime Past 30 days Lifetime Past 30 days
Cambodian-American Adolescent Survey (CAAS) 10th graders (N = 439)
Total CAAS 36.45% 20.50% 11.39% 22.10% 10.48% 15.03% 5.92%
Males 37.38% 21.96% 12.15% 21.03% 9.35% 15.89% 6.07%
Females 35.56% 19.11% 10.67% 23.11% 11.56% 14.22% 5.78%
Monitoring the Future (MTF) 10th graders (N = 15,330)
Total MTF 56.10% 27.80% 15.30% 34.60% 17.90% 29.60% 11.50%
Males 55.40% 28.50% 16.80% 37.90% 21.00% 31.50% 12.80%
Females 56.60% 26.90% 13.70% 31.30% 14.70% 27.40% 10.10%
California Healthy Kids Survey (CHKS) --Long Beach Unified (average of N = 846 9th graders and N = 847 11thgraders)2
Total CHKS 54.00% 28.00% -- 39.00% 20.00% 18.50% 8.00%
Males 51.06% 26.32% -- 40.21% 21.37% 20.37% 9.32%
Females 57.67% 30.52% -- 37.57% 18.10% 18.57% 6.52%
Chi-square comparisons (df =1)
CAAS vs. MTF
Total 66.63*** 11.37*** 5.06* 29.59*** 16.13*** 43.81*** 13.21***
Males 27.23*** 4.38* 4.38 25.25*** 17.20*** 23.65*** 8.54**
Females 39.20*** 6.77** 6.77 6.84** 1.73 19.24*** 4.54*
CAAS vs. CHKS
Total 42.93*** 10.08** -- 43.46*** 21.36*** 2.87 2.15
Males 12.72*** 1.70 -- 27.03*** 16.01*** 2.17 2.27
Females 35.10*** 11.51*** -- 16.53*** 5.48* 2.32 0.17
Open in a new tab
*

p< .05;

**

p< 01;

***

p< .001;

1

past two week heavy drinking item not included in CHKS data

3.2 Marijuana Use

Significantly fewer Cambodian-American youths reported having used marijuana in their lifetimes (22.10%) or in the past 30-days (10.48%) relative to either other US 10th graders (34.60% for lifetime, 17.90% for past 30 days) or to their peers in the same school district (39.00% for lifetime, 20.00% for past 30 days). A similar pattern of results was found when the samples were stratified by gender, however no significant difference was found with respect to female Cambodian-American youth and the other females in the same school district.

3.3 Cigarette Use

Cambodian-American youths had significantly lower rates of lifetime (15.03%) and past 30 day (5.92%) cigarette use relative to other U.S. 10th graders (29.60% for lifetime, 11.50% for past 30 days), a pattern which also held for male and female subgroups. In contrast, the differences in cigarette use between Cambodian-Americans and their peers in the same school district (18.50% for lifetime, 8.00% for past 30 days) were not statistically significant.

4. Discussion

This study assessed the substance use behavior of a representative sample of 10th grade children of Cambodian refugees living in Long Beach, California, the largest community of Cambodian refugees in the U.S. These Cambodian-American youth generally had lower rates of substance use relative to either other 10th graders across the U.S. or to their 9th and 11th grade peers in the same school district. Specifically, they were significantly less likely to consume alcohol, marijuana, and cigarettes relative to other 10th graders in the U.S. and they were significantly less likely to consume alcohol and marijuana relative to their peers in the same school district. Rates for cigarette use were not different between Cambodian-American youth and peers in the same school district and were generally quite low. Encouragingly, broader population-based studies also highlight low rates of cigarette use within California for adolescents (CDC, 2011; SAMHSA, 2012); even more so for Asian-American youth (Wong et al., 2004).

These findings do not support concerns that Cambodian-American youth may be at high risk for substance use (Lee et al., 2008; 2010; Makimoto, 1998). Even given the parental stressors presented to this specific subgroup (e.g., their parents are a disadvantaged Asian subgroup generally reporting poor mental health; Marshall et al., 2005), we found that Cambodian-American youths reported less use of substances relative to their peers. Perhaps protective factors for substance use similar to those among Cambodian and Cambodian-American youth (e.g., school attachment, family support, positive coping skills) are also evident in these Cambodian-American youth (Lim et al., 2011; Yi et al., 2011). The sample was also collected from an ethnic enclave of Cambodian families, which may have served a protective function given the shared collectivism, cultural norms, and views about substances (e.g., abuse of alcohol and drugs seen as embarrassing) in Asian-American enclaves (Mazumdar et al., 2000), which has explained differences in White and Asian adolescent substance use patterns in other work (Au & Donaldson, 2000). Members of ethnic groups who live in areas concentrated with others of similar ethnicity report lower rates of substance abuse than those living in neighborhood with less concentration of similar-ethnicity individuals (Molina, Alegria, & Chen, 2012). Also, it is noteworthy that the Cambodian youth in our sample were all born in U.S. and therefore did not experience the traumas their parents may have experienced in Cambodia first-hand. Refugee youth who experienced trauma first-hand in Cambodia may similarly suffer high rates of PTSD as their parents (and thus may also report high levels of substance use). Promising treatments and guidelines for clinicians working with refugee youth born overseas are available (Ehntholt & Yule, 2006; Wycoff, Tinagon, & Dickson, 2011).

Although our findings suggest Cambodian-American adolescents are at lower risk for substance use than the broader adolescent population, some Cambodian-American youths do use substances and some may do so in excessive amounts. For example, approximately one-fifth of the sample reported current drinking, roughly 1 in 10 reported current marijuana use, and about 1 in 17 reported current use of cigarettes. Thus, targeted prevention/intervention efforts for Cambodian-American adolescents are still needed. Future research is required to determine whether these youth would respond to standard strategies or whether they might benefit from interventions tailored to be culturally-responsive (Fang et al., 2011; Sue et al., 2012). For example, promoting limited substance use among youth in this ethnic group use by highlighting cultural norms around moderation may assist in the preventative effort (Makimoto, 1998). Further cultural-specific efforts may be warranted particularly since Asian-Americans may, for cultural reasons, underutilize services for mental health and substance use (Kim & Omizo, 2003; Le Meyer et al., 2009; Wang et al., 2005). While Cambodian refugee adults report high use of services for mental health concerns (Marshall et al., 2006), the quality of this care and youth engagement in care is understudied. In addition, the reasons for using substances may differ between racial/ethnic groups. Though we did not look at reasons for use in the CAAS sample, the Cambodian youth that do use may do so as a coping strategy. For example, other work has found Indochinese youth were more likely to drink for coping-related reasons (e.g., a means to forget past experiences) compared to Whites, Hispanics, and African Americans (Morgan, Winguard, & Felice, 1984). Teaching positive coping skills for dealing with stressful situations may be an avenue to pursue with these youth, as prior work has found positive coping skills to be associated with reduced use of substances among Cambodian and Vietnamese adolescents (Lim et al. 2003).

4.1 Limitations

In interpreting these findings, certain limitations of our study design should be considered. First, our sample was restricted to students attending 10th grade in a single public school system. Although this district is the sole public school system in the city that is home to the largest concentration of Cambodian refugees in the U.S. (Quintiliani & Needham, 2008), our findings may not be representative of the broader population of Cambodian-American adolescents residing outside of Long Beach. In addition, differences in response options for the three studies precluded precise comparisons of quantity and frequency of consumption. Finally, we compare our sample to 10th graders in the CHKS sample since data was not available. Though we took the average of 9th and 11th graders’ data from the CHKS, it should be noted that findings were consistent regardless of whether we compared CAAS data to 9th grade only, 11th grade only, or the average of the two grades. Finally, in the absence of collateral reports or biological samples, findings are based on self-report, which may be subject to bias. However, the amount of bias resulting from the use of self-report has often been exaggerated (Chan, 2009) and research indicates self-report of substance use among youth is valid when confidentiality is discussed (Harrison et al., 2007), as it was in the three samples here.

4.2 Conclusion

In conclusion, our findings that Cambodian-American youth use substances at rates lower than national and regional norms should not impede additional research with this subgroup. More research is needed to identify risk factors that might help to detect current or potential for heavy substance use among this subgroup, as well as better understand the protective factors associated with limited use by these youth. Further efforts are also needed to understand how to connect those suffering from substance use and mental health concerns with helpful services in the community.

Research Highlights.

  • We compared Cambodian-American youth substance use to national and local norms

  • Cambodian-American youth were less likely to use alcohol, marijuana, and cigarettes

  • Cambodian-American youth may not be at especially high risk for substance use

Acknowledgment

This research was supported by a grant from the National Institute of Mental Health (R01MH082069). We express appreciation to the RAND Survey Research team, led by Judy Perlman, M.A., and Richard Garvey, for help with data collection. Finally, we are indebted to the research participants who made this study possible.

Role of Funding Sources

NIMH had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Contributors

Dr. Pedersen prepared a first draft of the manuscript and edited a final version of the paper. Drs. Marshall, Schell, Wong, and Berthold designed the study, wrote the research protocol, assisted with conceptualization of the manuscript, and assisted in drafting specific sections of the paper. Dr. Schell and Ms. Hambarsoomian conducted the data analyses. All authors contributed to and have approved the final manuscript.

Conflict of Interest

All authors declare that they have no conflicts of interest.

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