Substance Use & Misuse, 49:1054–1063, 2014 C 2014 Informa Healthcare USA, Inc. Copyright  ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2014.850277

ORIGINAL ARTICLE

Place Matters in Perceived Tobacco Exposure Among Korean American Young Adults: Mixed Methods Approach Jimi Huh1 , James Paul Thing1 , Zarina Sabrina Abramova1 , Mojgan Sami2 and Jennifer Beth Unger1 1

Department of Preventive Medicine, Institute for Prevention Research (IPR), University of Southern California, Los Angeles, California, USA; 2 School of Social Ecology, University of California Irvine, Irvine, California, USA cents express higher levels of acceptability of cigarette smoking and the highest perceived prevalence of smoking, compared with their counterparts from other Asian groups (Weiss & Garbanati, 2004). Similarly, KA college students report higher levels of exposure to parental and peer smoking than their Chinese counterparts (Myers, Doran, Trinidad, Klonoff, & Wall, 2009). Parental communication regarding cigarette use, which can buffer the effects of perceived social norms, is lacking among Asian American families in general (Shakib et al., 2003). KA young adults also believe that it is hypocritical for a family member who smokes (e.g. father) to provide advice to abstain from cigarette use or quit smoking (Huh, Sami, Abramova, Spruijt-Metz, & Pentz, 2013). This cultural climate is likely to contribute to more permissive views about cigarette use among young people, which can affect their intention to smoke and actual uptake of smoking.

A sequential mixed methods study was conducted to identify factors influencing perceived norms about smoking and to examine the association of acculturative contexts and normative beliefs among Korean American young adults (KAYA) who face increased risk of smoking. Content analysis of data from 67 participants in 10 focus groups in 2010 led to the development of an online survey in 2012 (N = 475). KAYA overestimated smoking prevalence, reporting Korean-owned businesses (KOB) as primary places of exposure. Our findings revealed that visits to KOB predicted perceived norms about smoking. Modifying perceptions about social norms and involuntary tobacco exposure may be critical in reducing smoking among KAYA. The study’s limitations are noted. Keywords smoking, Korean American young adults, mixed methods, perceived norms, acculturation, involuntary tobacco exposure, social norms

Theoretical Background of Social Norms on Smoking and Acculturation

Health behavior models based on social learning (Akers & Lee, 1996) and planned behavior theories (Azjen, 1985) posit that normative beliefs (i.e., the extent to which one perceives a behavior as being “prevalent” or “normative”) are important precursors to forming intentions to engage in unhealthful behaviors, such as smoking, subsequently leading to actual unhealthy behaviors. Social learning theory asserts that behaviors are acquired by positive and negative sanctions associated with the behaviors and alternate behaviors (Akers, Krohn, Lanza-Kaduce, & Radosevic, 1979). In addition to acknowledging nonsocial reinforcers (e.g., physiological factors associated with nicotine addiction), social learning theory emphasizes that behaviors are learned, defined, and reinforced through interaction with others in one’s social groups

INTRODUCTION Cigarette Use and Young Korean American Adults

Korean American (KA) males show one of the highest smoking rates (ranging from 31.2%–38.7%) among ethnic minorities in the United States, substantially greater than the national average (21.6%) (An, Cochran, Mays, & McCarthy, 2008; Kim, Ziedonis, & Chen, 2007) and smoking rates among Asian American female youths are a growing problem (Kandula, Wen, Jacobs, & Lauderdale, 2009). Cigarette use in South Korea is even more prevalent than among KA in the United States, especially among males (estimates range from 52.8%–67.0%; (World Health Organization [WHO], 2002). In addition to the higher than average smoking rates, KA adoles-

This work was supported by the Tobacco-Related Disease Research Program (TRDRP 19FT-0089) and National Cancer Institute, Institutional Research Training Program in Cancer Control and Epidemiology (T32 CA009492). We thank our participants for providing valuable information. We also acknowledge the assistance from Euikyung Shin, Shelby Rusu, Todd Choi, Michelle Kang, and Aditi Jayaraman. Address correspondence to Jimi Huh, 2001 N. Soto Street, 302Y, MC 9239, Los Angeles, CA 90032-3628, USA; Email: [email protected]

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and that interpersonal definitions of behaviors can serve as direct reinforcers of those behaviors (Akers et al., 1979). For young adults with multiple cultural backgrounds, norms depend on how one defines his or her referent group in a given context. In other words, the way they perceive norms in a given situation or context depends on how one defines their referent group (e.g., Korean or “American”). Bicultural individuals (e.g., Korean Americans) are able to access both (i.e., Korean and the dominant U.S.) cultural-related frameworks and switch between the two with ease as they hold more complex and richer knowledge about both cultures, compared with individuals with monocultural background (Ringberg, Luna, Reihlen, & Peracchio, 2010). Further, their relationships with both cultural frameworks are dynamic as they evolve over time, and the relative magnitude of the influence by each cultural framework varies across individuals. This dynamic process is referred to as acculturation, a dynamic, nonlinear, multifaceted multidimensional process (Schwartz, Unger, Zamboanga, & Szapocznik, 2010) which immigrants and their offspring experience while adjusting their cultural practices, beliefs, and norms with those of the host culture. Among Asian American adolescents, low levels of acculturation of to the dominant U.S. culture are associated with more permissive attitudes toward smoking among Asian American adolescents (Weiss & Garbanati, 2004). Studies addressing the direct effects of acculturation on perceived norms of smoking have focused primarily on adolescents (e.g. Unger et al., 2000; Weiss & Garbanati, 2004; Weiss, Garbanati, Tanjasiri, Xie, & Palmer, 2006). Research is needed to examine the role of perceived norms in early adulthood (18–25 years old), a critical but understudied age group in forming habits including substance use that tend to persist throughout adulthoodsup¿ (Arnett, 2000). Young adults typically begin to experience a wide range of novel situations as they transition into independence (Arnett, 2000) and the factors that affect perceived norms during this transition merit further investigation as young adults’ primary environments are likely to shift from their environments during adolescence, namely home or school settings. There are available studies that help elucidate this relationship, however, the majority involves college students (e.g., Myers et al., 2009), who differ from their noncollege attending counterparts with respect to high school completion rates, career goals, and/or willingness to engage in problematic behaviors (e.g., substance use) (Crowley, 1991). Finally, research has not focused on ethnic Asian minority subgroups who may face increased risk of tobacco exposure and use, due, in part, to Korean and Korean-American cultural norms which facilitate and encourage the adoption of permissive personal and group attitudes and behaviors with regard to smoking. Therefore, additional research is needed in examining how cultural factors influence attitudes among KA young adults in an effort to prevent them from smoking initiation and/or continued smoking.

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Normative attitudes and behavior patterns of smoking embedded in social networks is highly salient in determining the likelihood of smoking among individual members of social networks (Christakis & Fowler, 2008). As predicted by social learning theory, close friends and peers are very influential on the smoking patterns of young adults whose familial influences may wane during this time period (Andrews, Tildesley, Hops, & Li, 2002). Research on Cambodians (Friis et al., 2012) and Filipinos (Garcia, Romero, & Maxwell, 2010) in California, and Cambodians, Chinese, Taiwanese, and Vietnamese in Washington (Spigner, Shigaki, & Tu, 2005) suggests that affective ties to coethnics generally, and especially coethnic friends, who smoke contribute significantly to increased smoking rates, most notably, among men. Importance of Mixed Methods

In a recent review article on tobacco use among Asian Americans, Kim et al. (2007) call for qualitative research to explore in-depth the importance of cultural norms among subgroups of Asian Americans, followed by a subsequent, “culturally-anchored” quantitative study. Further, triangulating quantitative and qualitative work has been found to be effective in obtaining affect-oriented, idiosyncratic information (e.g. Creswell, 2007; SpruijtMetz, Gallaher, Unger, & Anderson-Johnson, 2004). Despite these advantages, studies employing mixed methods in tobacco research are rare, and to the authors’ knowledge, this is the first mixed methods study to explore cultural factors that contribute to perceived smoking prevalence among Korean American young adults (KAYA). Measurement of Acculturation

The single-item proxy measures widely used in current research to assess acculturation and tobacco use among Asian American adults are English proficiency, years of U.S. residency, or language/social/food preference (Kim et al., 2007). Hunt, Schneider & Comber (2004) challenged the notion of acculturation and its putative effects on health, criticizing the lack of a clear definition and conceptualization of the construct when used in the health literature. Other studies that involved acculturation scales such as the Suinn-Lew Self-Identity Acculturation (e.g. Ownbey & Horridge, 1998) have been criticized for use of a composite score since such usage of the scale simplifies the effects of acculturation on outcome variables and also implies that acculturation is a single latent construct (Salant & Lauderdale, 2003). In addition to issues regarding the theoretical aspects and measurement of acculturation, some researchers speculate that different dimensions of acculturation may have distinct effects, depending on the health outcomes of interest (An et al., 2008; Hunt et al., 2004; Salant & Lauderdale, 2003; Schwartz et al., 2010). Rather than using the existing psychometric scales, clearer definitions and underpinnings of the construct are likely to emerge with exploratory approach such that specific dimensions of acculturation related to smoking and involuntary exposure to

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tobacco can be identified. In fact, acculturative contexts important for forming subjective norms and, ultimately, cigarette use are to be identified by conducting qualitative investigation. In the current study, we used a multifaceted approach in assessing acculturative contexts that extends beyond language use. In this regard, the fruits of this investigation will contribute to a deeper understanding of acculturation assessment. This study, using mixed methods, examines the influence of acculturation on perceived social norms regarding smoking and involuntary tobacco exposure among KAYAs from diverse backgrounds. The goals of this study are to identify cultural factors influencing perceived norms (1) through a qualitative investigation, and (2) by cross-validating the qualitative data with subsequently collected survey data and by testing the hypothesized association between specific acculturative contexts and perceived social norms of smoking and involuntary tobacco exposure among KAYA. METHODS Overall Study Design

This study employed a sequential design (Collins, Onwuegbuzie, & Jiao, 2007), using qualitative data obtained from 10 focus groups in Phase I, which informed the construction of survey items in Phase II. All participants provided informed consent prior to completing the respective study procedures; study protocols were approved by the Institutional Review Board. Phase I

Procedure Phase I used focus groups of KAYA to facilitate group discussions on experiences and perspectives from members of a group who share similar beliefs and norms (Creswell, 2007; Krueger & Casey, 2000). Sample A total of 67 KAYA participated in 10 focus groups (Mage = 20.77, SD = 1.77, averaging 6–7 participants per group). Participants were recruited from Orange, Los Angeles and San Bernardino Counties in California, from communities with large Korean American ethnic enclaves (e.g. Cerritos, Fullerton, Korea Town in Los Angeles) through social media (e.g. Facebook) and word of mouth. The eligibility criteria included: 18 to 25 years of age and a Korean or Korean American self-identity. Focus groups were conducted between November 2010 and March 2011. Four groups were conducted in Korean and six in English. There were more smokers participating (50.7%) than nonsmokers (37.3%), and eight participants (11.9%) were former-smokers. There were slightly more male participants (53.7%) than females, and almost half of the participants (49.3%) reported being born in the United States. The full characteristics of the focus groups can be found elsewhere (Huh et al., forthcoming). Participants responded to open-ended questions relating to their experience with tobacco, how cigarette smoking is viewed in

Korean culture, and how they felt about exposure to tobacco in public places. Analysis Atlas.ti V6.2 was used to conduct content analysis. The lead author (JH) and an independent research assistant who are native Korean language speakers independently coded transcripts conducted in Korean and later reconciled. Korean transcripts were not translated in order to preserve the original language. Phase II

Procedure Participants were recruited via social media sites (e.g. Facebook, Kakaotalk) to partake in a 15 to 20 min online survey in their preferred language (hosted by Survey Monkey). The research assistants recruited through the following process: sending private social media messages to KA network peers using corresponding sites, posting a “general status” to all social media peers in order to network in the KA community, and creating an online open Facebook group to share the study information and make updates with particular group of network peers. Screening questions included self-reported ethnicity and age. If the age (18–25 years) and ethnicity (Korean or Korean American) criteria were unmet, participants were directed to a thank-you page. Sample From June through October of 2012, we recruited 475 KAYA (Mage = 21.1, SDage = 2.2; 56.3% female). About half (50.7%) of the sample participated in online survey in Korean language and slightly more females (56.3%) participated. Approximately 25% were current smokers; 44.5% were in workforce; 43.4% visited Korean-owned businesses (KOB) twice or more per week; 53.4% identified themselves as “Koreans” or “Koreans living in United States” as opposed to “Korean Americans” or “Americans” (see Table 1). Measures Demographic characteristics and smoking status: Participants indicated their age, sex, and ethnic identity, and whether they currently smoke cigarettes (yes or no). Acculturation orientation: The Acculturation, Habits, and Interests Multicultural Scale for Adolescents (AHIMSA) Acculturation Scale (Unger et al., 2002) was used (standardized Cronbach α = .75). The three subscales of the AHIMSA were used as a measure for level of assimilation (i.e. preference for the U.S. culture), separation (i.e. preference for Korean culture), and biculturalism (i.e. preference for the U.S. culture and for Korean culture in most contexts). Because of the scoring methods of the scale, we excluded the marginalization subscale to avoid linear dependence (Unger et al., 2002), and because the marginalization subscale also showed little variability. Frequency of visits to KOB: Participants were asked to indicate how often they visit Korean-owned businesses

PLACE MATTERS IN PERCEIVED TOBACCO EXPOSURE AMONG KOREAN AMERICAN YOUNG ADULTS

TABLE 1. Descriptive statistics (N = 475) M Age Survey in Korean language (vs. English) Female Current smoker Full-time student Ethnic identity Korean Korean living in the U.S. Korean American American AHIMSA subscale US Orient. Korean Orient. Biculturalism Marginalization Perceived prevalence (%) among Peers U.S. Caucasians Korean Americans Korean American men Korean American women Frequency of visits to KOB Belief that thirdhand smoke is harmful for infants Factor score for the SAS smoking restriction subscale

%

21.10

SD 2.17

50.73 56.34 24.52 55.14

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Data Analysis A series of multiple regression models were developed to assess the unique effect of KOB on various measures of social norms, controlling for other key acculturation variables. All analyses were conducted in SAS V9.2. RESULTS Phase I

23.81 29.65 44.81 1.73

Two themes emerged in the content analysis: (1) overestimate of smoking rates in ethnic enclaves and (2) misperceptions of smoking rates in Korean-owned businesses. These themes are further explored in the Results section.

2.09 1.65 3.75 .19

2.20 2.03 2.26 .69

26.12 44.64 63.52 70.20 43.96 2.38 5.29

10.99 19.19 20.18 20.65 20.93 .91 1.76

18.11

7.18

such as grocery markets, karaoke bars, and restaurants. The response options ranged from 1 = About once per month, 2 = About once per week, 3 = More than 2 times per week, but less than seven times a week to 4 = Almost daily. Perceived norms about smoking: Participants were asked to indicate free response to the following questions: “What% of your close friends smoke?” In addition, they were asked to provide estimated smoking rates for the following groups: Caucasian Americans, Korean Americans, Korean American men, and Korean American women. Attitude toward involuntary tobacco smoking: Thirdhand smoke refers to exposure to lingering tobacco toxins long after active smoking dissipates (Winickoff et al., 2009). A single-item was used to assess the attitude about third-hand smoke: “Breathing air in a room today where people smoked yesterday can harm the health of infants and children” (Winickoff et al., 2009). To assess views toward smoking restrictions and laws, factor score of the 7-item subscale from the Smoking Attitude Scale (SAS; Shore, Tashchian, & Adams, 2000) was used (standardized Cronbach α = .74). Example items included: “There is no good reason to ban smoking on airplane flights,” “Restricting smoking in public places is unfair to smokers,” Response options for all attitude items ranged from “strongly disagree (= 1)” to “strongly agree (= 7)”. All the measures were translated to Korean by an independent translator and back translated to English by the lead author (JH) to check for inconsistencies. Any inconsistencies were addressed through discussions.

Overestimation of Smoking Rates among KAYA in Ethnic Enclaves Most participants, regardless of their own smoking status, perceived an extremely high prevalence of smoking among their KAYA peers and in Korean ethnic enclaves. When asked to approximate percentage of students who use cigarettes in high school, one smoker participant, commenting on the smoking habits of Koreans in general and on his high-school experience, specifically, responded: “Ninety-nine percent, yeah, among Koreans. [in the] Korean community. Even the ones [students] that you never thought smoked will smoke.”

This pattern of perceived high prevalence of smoking among KAYA persists in college as noted by another smoker participant who commented: “[City ‘C’] is like the ‘smoking’ area . . . we, all my friends, smoke. Literally all of them - the ones that I see on a daily basis and when we are studying in the library somewhere they will step out for a cigarette.”

Another Korean speaking smoker participant attributed his own smoking behaviors, which included an increase in cigarette smoking, to entering Korean-dominant social networks when he started college: “In my opinion, the reason I started to smoke more since I started college, was the people with whom I associate. Since I came here to California, I got to hang out with more Korean people.”

The perception of high rates of smoking among KAYA high school and college students was nearly ubiquitous among participants and a few participants associated smoking with the social dynamics relating to forming relationships with other KAYA. One commented: “I serve as a staff person for Korean club [at university], where I got to meet a lot of smokers. And, cigarette smoking is really the medium to get close to someone, initially.”

Korean-speaking, nonsmoker participants provided similar overestimations of smoking rates among KAYA in the United States and in Korea. One participant, referring back to the days before he moved to the United States: “When I lived in Korea, all my friends, except for me, used to smoke cigarettes.”

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Finally, some participants expressed—and others gittily agreed—that acquiring smoking habits was viewed as almost “natural” for Koreans since, as one participant put it: “Basically, [smoking] is in our blood.” When the moderators informed the participants of the observed smoking prevalence among the American general population (∼22%) and Korean Americans (∼37%), respectively, almost all participants expressed their surprise. Misperceptions about Smoking Rates in Korean-Owned Businesses Several participants identified Korean-owned businesses (KOB) and other places popular among Korean Americans, such as pool halls, Karaoke clubs, caf´es, bars, and restaurants in ethnic enclaves (e.g., K-town in Los Angeles) as common places for tobacco exposure—and most participants nodded in agreement. Similarly to participants’ exaggerated overestimates of smoking patterns among KAYA, most participants perceive smoking in Korean enclaves as nearly ubiquitous. An English-speaking, nonsmoker participant commented: “I think that everybody smokes in Korea town” (emphasis added)

Another commented: “It’s not even to look cool. It’s just like a trend. If you didn’t smoke, everyone thought you’re weird or something. So . . . after that you know addiction comes in. After I moved out [the city] ‘L’ to [some other] community, I kind of quit because I wasn’t with those guys anymore. And then I met some more Koreans at church, that’s when I started smoking again.”

The latter participant, when asked to comment on relative acceptability of smoking in Korean culture vs. U.S. culture, jokingly indicated that smoking is so prevalent in Korean ethnic enclaves it is “like oxygen”. Most participants laughed and nodded in agreement. His comment suggests that not only is smoking may be prevalent in Korean enclaves, and that pervasive, highly permissive norms regarding smoking may be responsible for a lack of regulation in these enclaves. “If you smoke in Korea town, it’s kind of given that everyone smokes and it doesn’t really bother them so it’s no big deal to anyone else. So, you can smoke inside and there might be one or two that do not smoke and are bothered by it. Generally there are people that smoke and are fine with it. I think that’s why there is less regulation.”

For those who currently smoke or are former smokers, some associated their smoking habits, specifically an increase in smoking, to changes in their habitat and social environment, especially living and socializing in Korean enclaves.

In contrast, a few—a clear minority of —participants expressed that they believed that: “[rules and regulations in Korean ethnic enclaves regarding smoking] are slowly changing and are getting better,” because Korean establishments are being regulated more often to assess if those rules are being enforced.

“After I came back to home in City ‘L’, I’ve been smoking with my friends in City ‘L’. Then, I started college, I continued to smoke.”

Phase II

In addition to changes in physical environments, several participants feel pressure to conform to social norms—including smoking—due to changes in social environments and networks, specifically, an increase in the density of Korean American social networks, pressure One KAYA said: “I grew up in Korea town, in City ‘L’. It was basically like a trend. If you don’t smoke, you are kind of considered as a loser . . .

Descriptive Statistics The results document that KAYA’s perceived smoking prevalence rates for all groups are substantially higher than the actual prevalence (see Table 1). In Figure 1, univariate distributions of the perceived prevalence rates among U.S. Caucasian population and Korean American males are provided. The vertical black reference lines represent the documented smoking rates and are provided for comparison purposes. This misperception is especially pronounced for that of Korean American males.

FIGURE 1. Histogram of the perceived prevalence rates among U.S. Caucasian population and Korean American males with reference vertical line representing the documented smoking rates.

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Zero-order correlation revealed that frequency of visits to KOB was significantly correlated to all perceived prevalence outcomes (r’s ranging from .10–.25, p < .05). The survey language of preference was not related to perceived smoking rates (p > .07). None of the AHIMSA subscale was related to perceived smoking rates (.09 < p < .80). The results of multiple regression analyses are presented in Table 2. The frequency of visits to KOB was positively related to perceived peer smoking rates (b = .20, p < .001), among the U.S. general population (b = .28, p < .01), Korean Americans (b = .35, p < .01), and among Korean American men (b = .37, p < .001), controlling for age, sex, survey language, student status, the AHIMSA subscales, and current smoking status (Model 1). Interestingly, the frequency of visits to KOB did not significantly predict perceived smoking rates among Korean American women (b = .20, n.s.). We tested the interaction between smoking status and visits to KOB. Among nonsmokers, the frequency of visits to KOB was positively related to perceived peer smoking rates (b = .13, p < .05). This positive effect of visits to KOB on perceived peer smoking rate was amplified for smokers (b = .21, p < .05, see Model 2). The effects of KOB for the perceived smoking rates among U.S. general population (b = .38, p < .01), Ko-

rean Americans (b = .37, p < .01), and Korean American men (b = .38, p < .01), however, did not differ between smokers and nonsmokers controlling for age, sex, survey language, student status, and the AHIMSA subscales (see Model 2). The results regarding involuntary tobacco smoking are presented in Table 3. Those who took the surveys in Korean (vs. English) less strongly believed that third-hand smoke was harmful for infants and children (b = −.67, p < .001), controlling for age, sex, student status, the AHIMSA subscales, visits to KOB, and current smoking status. There was no interaction between survey language and smoking status. In contrast, those who took the surveys in Korean (vs. English) showed higher factor scores for negative views about tobacco restrictions in public places (b = 4.53, p < .001, see Model 1). This relationship was moderated by current smoking status. Among nonsmokers, those who completed the surveys in Korean more strongly agreed with this statement (b = 5.73, p < .001). For smokers, the effect of survey language on views about restrictions was significantly dampened (b = −5.83, p < .001, see Model 2). For detailed group comparisons of the SAS smoking restriction individual items, see Table 4.

TABLE 2. Multiple regression models predicting perceived smoking prevalence

AHIMSA U.S. Orient. Korean Orient. Bicultural Current smoker (yes) Frequency to visits to KOB Current smoker × KOB

AHIMSA U.S. Orient. Korean Orient. Bicultural Current smoker (yes) Frequency to visits to KOB Current smoker × KOB ∗

Among peers (N = 448)

Among Caucasian Americans (N = 421)

Among Korean Americans (N = 421)

Model

Model

Model

1 B(SE)

2 B(SE)

1 B(SE)

2 B(SE)

1 B(SE)

2 B(SE)

.16 (.05)† .16 (.05)† .18 (.05)† .92 (.12)†† .20 (.05)††

.15 (.05)† .15 (.05)† .18 (.05)† .37 (.29) .13 (.06)∗ .21 (.11)∗

−.08 (.12) −.01 (.13) −.06 (.12) .31 (.24) .28 (.11)†

−.09 (.12) −.02 (.13) −.07 (.12) 1.09 (.60) .38 (.13)† −.32 (.22)

.05 (.13) .04 (.13) .06 (.13) .71 (.25)† .35 (.11)†

.05 (.13) .03 (.13) .06 (.13) .85 (.63) .37 (.13)† −.05 (.23)

Among Korean American men (N = 422)

Among Korean American women (N = 422)

Model

Model

1 B(SE)

2 B(SE)

1 B(SE)

2 B(SE)

.03 (.13) .06 (.13) .02 (.13) .64 (.25)∗ .37 (.11)†

.02 (.13) .06 (.13) .02 (.13) .71 (.65) .38 (.14)† −.03 (.24)

−.06 (.13) −.14 (.14) −.12 (.13) .80 (.26)† .20 (.12)

−.06 (.13) −.14 (.14) −.12 (.13) 1.04 (.66) .23 (.14) −.09 (.24)

p < .05; † p < .01; †† p < .001. The model controls for age, language of the survey, gender, and employment status (full-time student vs. in workforce).

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TABLE 3. Regression models predicting attitudes toward environmental tobacco exposure Thirdhand smoke harmful for infants (N = 435)

Smoking restriction factor score (N = 435)

Model

Model

AHIMSA U.S. Orient. Korean Orient. Bicultural Current smoker (yes) Frequency to visits to KOB Current smoker × survey in Korean language

1 B(SE)

2 B(SE)

1 B(SE)

2 B(SE)

.09 (.10) .09 (.10) .11 (.10) −.40 (.21) −.10 (.09)

.09 (.10) .09 (.10) .11 (.10) −.39 (.32) −.10 (.09) −.00 (.40)

.16 (.36) .24 (.37) .25 (.37) 3.47 (.83)‡ −.64 (.37)

.14 (.36) .24 (.37) .26 (.36) 7.05 (1.25)‡ −.58 (.36) −5.83 (1.56)‡

∗ p < .05; † p < .01; ‡ p < .001. The model controls for age, language of the survey, gender, and employment status (full-time student vs. in workforce).

DISCUSSION

The results of our content analyses in Phase I provided us with culturally informed insight to further explore perceived tobacco exposure and related norms among KAYA. Three themes linking perceived tobacco exposure to KA social norms emerged from focus group discussions: extreme overestimation of smoking rates among KA and Korean populations, exaggeration of smoking rates and acceptance of smoking in Korean enclaves, and the role of smoking in social bonding and in the formation of relationships among KA. While adolescents who smoke tend to overestimate the prevalence of smoking rates

among their friends (Andrews et al., 2002), our research illustrates that KAYA overestimate—whether smokers or not—not only the prevalence of smoking among their friends, but also among coethnics in their neighborhood communities. Social learning theory suggests that there is a direct relationship between individuals’ smoking behaviors and norms regarding smoking and that this relationship is also influenced by perceived norms of others with whom they come either direct or indirect contact. According to this model, the smoking behaviors and norms of valued others (e.g., parents, siblings, and friends) are considered central to the formation of their normative beliefs about smoking

TABLE 4. Pairwise comparison for individual SAS smoking restriction individual items

There is no good reason to ban smoking on airplane flights Restricting smoking in public places is unfair to smokers. Laws restricting smoking in the workplace are unfair to smokers. People should have the right to smoke where and when they want. Smoking should not be restricted by law in any way Nonsmokers should learn to be more tolerant of smokers. 1 vs. 2 p < .05. 1 vs 3 p < .05. c 1 vs 4 p < .05. d 2 vs 3 p < .05. e 2 vs 4 p < .05. f 3 vs 4 p < .05. a

b

Korean-speaking smokers (n = 70)

English-speaking smokers (n = 38)

Korean-speaking nonsmokers (n = 170)

English-speaking nonsmokers (n = 181)

3.70 (1.63)

2.45 (1.94)

2.64 (1.59)

1.61 (1.38)

a, b, c, e, f

3.11 (1.56)

3.78 (1.86)

3.98 (1.78)

2.33 (1.66)

b, c, e, f

3.99 (1.78)

3.46 (1.61)

2.79 (1.64)

2.39 (1.57)

b, c, e

3.48 (1.61)

3.81 (1.66)

2.85 (1.71)

2.57 (1.71)

c, d, e

3.70 (1.48)

3.98 (1.99)

2.95 (1.81)

2.55 (1.73)

b, c, d, e

3.06 (1.55)

3.92 (1.57)

4.84 (1.91)

3.00 (1.93)

b, d, e, f

Pairwise comparison, Bonferroni-adjusted

PLACE MATTERS IN PERCEIVED TOBACCO EXPOSURE AMONG KOREAN AMERICAN YOUNG ADULTS

and subsequent decision to smoke (Collins & Ellickson, 2004; Kobus, 2003). Secondary referent groups, including community members, however, also heavily affect the normative beliefs and smoking behaviors of individuals (Christakis & Fowler, 2008; Kobus, 2003). Thus, individuals’ smoking behaviors and beliefs about smoking can be considered social products. For the KAYA in this study, their exaggerated perceptions of the prevalence of smoking behaviors and permissive attitudes toward smoking among their KA peers, in KA enclaves and among KA in general appear to contribute to a cultural climate that may encourage smoking among KA. Because research shows that people choose their friends based on similarity with respect to characteristics such as race and ethnicity as well according to substance use behaviors (see Kandel, 1978a, 1978b; Kobus, 2003) including smoking (Andrews et al., 2002), KAYA may be at particular risk for smoking. Several participants in this study stressed that smoking facilitates forming social connections with other KAYA and that they initiated smoking, increased levels of smoking, or began smoking again after having quit, all in the context KAYA peers. Furthermore, when participants discussed their perceptions about tobacco exposure, important contextual information emerged regarding Korean-owned businesses in ethnic enclaves. These places were commonly mentioned as sources of tobacco exposure, which appeared to be associated with the levels of perceived smoking rates. This qualitative data led the investigators to generate hypotheses and test them in the subsequent study phase. The results of study Phase II supported our initial findings in which the frequency of visits to Korean-owned businesses was positively associated with perceived overestimation of tobacco use among their peer group, among the U.S. Caucasian populations, among Korean Americans, and Korean American males. The effects were highly robust suggesting that environmental contexts influenced perceived norms over and beyond other proxy acculturation measures commonly used in tobacco smoking research involving Asian American groups. The finding that the AHIMSA cultural orientations were not related to perceived norms warrants further investigation. It supports the argument by Hunt et al. (2004) and Salant and Lauderdale (2003) that the important aspect of acculturation depends on the outcome of interest. In our study, we showed that places are important in shaping one’s norms about smoking, rather than language use and preferred affiliates and/or customs. Our findings highlight the complex, multi-faceted nature of acculturation as it applies to specific health outcome. Together, these findings highlight the utility of a mixed methods approach in research with an underserved population. Our study shows that research on acculturative contexts affecting smoking norms among KAYAs may benefit by incorporating variables beyond language use such as social bonding. The results call for efforts to design culturally appropriate interventions to modify perceptions about social norms and involuntary tobacco exposure among Korean Americans. Such interventions should

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consider the status of policy enforcement in business establishments found in ethnic enclaves. More collaboration with the Korean American community and health organization is essential in modifying these perceptions. As shown in our study, the community contexts were critical in shaping KAYAs’ normative views on smoking. Establishing new, health-promoting norms would require support from this community, which eventually will lead to re-shaping of perceived norms about smoking among KAYAs. Improved enforcement of smoking prohibition laws and policies in businesses in Korean American communities would be critical. Although many of the current antitobacco programs in the United States promote a norm change approach (e.g. www.theTruth.com), supplemental, culturally sensitive approach would need to be developed and empirically tested. Interestingly, none of the acculturative measures were significantly associated with perceived norms for Korean American women, controlling for smoking status. The mean estimate of perceived smoking rate was still greatly inflated (∼44%) and yet notably lower than that for Korean American men (∼70%). Although our qualitative data informed us that views about female smoking are quite varied among these young adults and that participants with greater affinity to U.S. orientation (e.g. English-speaking, second-generation immigrants) expressed more permissive views about female smoking, our quantitative investigation revealed mixed results that did not reach statistical significance. It is also noteworthy that nonsmoking, Koreanspeaking participants showed greater tolerance for tobacco exposure in public places than their Englishspeaking counterparts. This finding is consistent with research that demonstrates an inverse relationship between acculturation and tolerance for involuntary tobacco exposure (Hughes, Corcos, Hofstetter, Hovell, & Irvin, 2009). That the preferred language did not have the same effects on negative attitudes about smoking restrictions among smokers also deserves further consideration. This might represent the prosmoking climate influenced by Korean/Korean American culture that withstands California’s comprehensive tobacco control measures. These cultural sentiments may be perpetuated and preserved within Korean-dominant community settings through interactions and observations by these KAYA. Study Limitations and Strengths

Although our recruitment method was effective in reaching a large sample size, the extent of generalizability of our findings is still limited due to the convenience sampling strategies. Use of social media is an effective tool when accessing the hard-to-reach communities, although data quality and clustering effects need to be cautiously considered. Nonetheless, to the best of our knowledge, this is the first study to identify culturally unique factors influencing perceived norms of smoking among KAYAs through qualitative investigation and to subsequently cross-validate the information with the survey data.

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This research provides culturally anchored insights that can help better serve tobacco control needs among these cultural group members who are often missed in large-scale, nationally-representative surveys. Our study findings call for efforts to design culturally appropriate interventions to modify perceptions about social norms and involuntary tobacco exposure among young Korean Americans. Collaboration with the Korean American community and business owners may be essential in modifying these perceptions.

Mojgan Sami, Ph.D., is an interdisciplinary scholar who explores the influences of an increasingly urbanized/built environment on ecological, health, and human security.

Declaration of Interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Jennifer Beth Unger, Ph.D. is Professor of Preventive Medicine at the University of Southern California Keck School of Medicine. Dr. Unger’s research focuses on the psychological, social, and cultural influences on health risk behaviors.

THE AUTHORS Jimi Huh, Ph.D., is Assistant Professor of Research at the University of Southern California, Keck School of Medicine. Her research focuses on multilevel contextual influences on health-related behaviors among underserved immigrant populations.

James Paul Thing is a postdoctoral fellow at the University of Southern California, Keck School of Medicine. His research focuses on sexuality, sexual health, HIV, and substance use among racialethnic minority communities.

Zarina Sabrina Abramova is currently pursuing MPH in the Environmental Health. She is interested in health disparities in tobacco and substance use among the underserved and underinsured populations.

GLOSSARY

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