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Smoking and Membership in a Fraternity or Sorority: A Systematic Review of the Literature a

a

a

Marshall K. Cheney PhD , LaNita W. Harris MPH CHES , Mary J. Gowin MPH & Jamie Huber a

BS a

Department of Health and Exercise Science, University of Oklahoma, Norman, Oklahoma Accepted author version posted online: 14 Feb 2014.Published online: 08 May 2014.

Click for updates To cite this article: Marshall K. Cheney PhD, LaNita W. Harris MPH CHES, Mary J. Gowin MPH & Jamie Huber BS (2014) Smoking and Membership in a Fraternity or Sorority: A Systematic Review of the Literature, Journal of American College Health, 62:4, 264-276, DOI: 10.1080/07448481.2014.891595 To link to this article: http://dx.doi.org/10.1080/07448481.2014.891595

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JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 62, NO. 4

Major Article

Smoking and Membership in a Fraternity or Sorority: A Systematic Review of the Literature

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Marshall K. Cheney, PhD; LaNita W. Harris, MPH, CHES; Mary J. Gowin, MPH; Jamie Huber, BS

Abstract. Objective: Fraternity and sorority members have higher rates of smoking than other college students. This systematic review examines studies that included fraternity/sorority membership in their investigation of smoking behaviors. Participants/Methods: Studies identified in MEDLINE, PsychInfo, JSTOR, CINAHL, ERIC, and Google Scholar published between 2003 and 2013 were included if they included fraternity and/or sorority membership, were written in English, published in a peer-reviewed journal, and had smoking as an outcome variable. Nineteen studies were identified for the review. Results: Fraternity/sorority members were more likely to be nondaily smokers. Members who lived in the fraternity/sorority house had higher rates of smoking than members who lived elsewhere. Fraternity/sorority member smoking was associated with alcohol and other substance use. The influence of no-smoking policies on fraternity/sorority member smoking was also examined. Conclusions: Fraternity/sorority membership was associated with higher rates of smoking, but this association was influenced by other substance use and environmental factors.

typical student at their school, estimates of ever use were much higher (93%), with students estimating 25% of typical students used cigarettes daily, indicating a perceived social norm for smoking among peers.5 Most college students who smoke say they plan to quit after college, but studies have shown that approximately half (55%) of college occasional and light daily smokers were still smoking at the end of their college years.8 This poses a significant public health threat, as it leads to increased risk of chronic illness and lower quality of life.1 A closer look at the college student population reveals differences in smoking rates among different groups of students. Members of fraternities and sororities have some of the highest smoking rates on campus.7,9–11 Fraternities and sororities are social networks that offer college students the opportunity to select a social group with similar preferences and attitudes.12 Fraternity/sorority members are governed by a shared set of rules that shape how members view others and how they describe themselves. These rules help members create a social identity through a lengthy and elaborate socialization process.12 The social structure of fraternities and sororities also provides social boundaries for attitudes, beliefs, and behaviors,13,14 which can include social norms for unhealthy behaviors such as smoking and alcohol use.15–17 Recent studies have examined the association of tobacco smoking in fraternity/sorority members, as well as the association of smoking with alcohol consumption and marijuana use.7,9,11,18–21 These studies have documented significant associations between tobacco use and fraternity/sorority membership, as well as significant associations with other substance use, but the associations are not always consistent across studies. The purpose of this systematic review22 was to (1) analyze studies of college student smoking behaviors that have included fraternity/sorority membership; (2) identify inconsistencies and gaps in the literature around the relationship

Keywords: fraternity, hookah, smoking, sorority, tobacco use

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oung adult smoking patterns have changed over the last 30 years. Eighteen- to 24-year-olds now have the highest smoking rate of any age group and an increased rate of nondaily smoking.1–3 College students have experienced a greater increase in their smoking rate than their counterparts who go straight to work from high school.1,3,4 Estimates of college student current (last 30 day) smoking rates range from 14%5 to as high as 29%; however, most college students do not smoke every day.6,7 A national study of college student health reported that although college students themselves reported a relatively low rate of ever smoking (30%), when asked to estimate use of cigarettes by the Dr Cheney, Ms Harris, Ms Gowin, and Ms Huber are with the Department of Health and Exercise Science at the University of Oklahoma in Norman, Oklahoma. Copyright © 2014 Taylor & Francis Group, LLC 264

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Smoking and Membership in a Fraternity or Sorority

FIGURE 1. Flow diagram of study selection.

between fraternity/sorority membership and smoking; and (3) provide next steps for researchers in understanding the relationship between membership in a fraternity or sorority and smoking tobacco. METHODS Studies were identified for the review using 6 search engines: MEDLINE, PsychInfo, CINAHL, ERIC, JSTOR, and Google Scholar. The search was limited to English language publications between January 2003 and February 2013. The literature was initially searched for “smoking” AND “sorority” then “smoking” AND “fraternity” in the abstract. Then, the literature was searched for “college” AND “smoking” with “sorority” OR “fraternity” in the body of the text (see Figure 1). VOL 62, MAY/JUNE 2014

Inclusion criteria for the review were (1) outcome variables included smoking tobacco in college students (this included cigarettes, little cigars, and cigars), (2) fraternity/sorority membership was included in the analysis, (3) the studies were conducted in the United States and written in English, and (4) studies were published in a peer-reviewed journal. Articles identified through the initial search inclusion criteria were screened based on title and abstract. Those studies that did not meet criteria for inclusion were excluded, leaving 24 studies for a full examination. Of these, 5 were excluded. In 3 studies the data were collected before 2000, 1 did not examine the relationship between membership in a fraternity or sorority and smoking, and 1 additional study was excluded because of inconsistencies in reporting results, leaving 18 studies for review. 265

Cheney et al

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Upon further examination of the literature, a decision was made to include hookah (water pipe) smoking in the review. Hookah smoking is an emerging smoking behavior becoming popular with young adults, particularly college students.1 Membership in a fraternity/sorority has been associated with hookah use, and college students often smoke both cigarettes and hookah.10,23,24 A second systematic review was conducted, and 4 articles were identified (see Figure 1). Three previously identified studies included hookah use and 1 additional peer-reviewed study was identified and added to the review, resulting in a total of 19 studies. RESULTS The 19 studies identified for review are summarized in Table 1. The studies reviewed in this section are discussed in 2 parts. First, a description of study characteristics is presented to assist in identifying the influences on study findings, followed by the synthesis of study findings. Study Characteristics Study Design The studies reviewed utilized a range of study methods, including cross-sectional surveys,7,10,11,19–21,23,25–28 longitudinal studies,6,9,18 an ecological study,29 qualitative studies,15,16 and a social network analysis.17 Almost all studies drew their samples either from a large university or across multiple universities. The exceptions being 1 study from a private university17 and 1 examining historically black colleges and universities.30 The diversity of study designs and larger sample sizes increases the generalizability of the studies, but is diminished in that multiple studies used the same sample or data set to answer different research questions (see Table 1). Response Rates The studies reviewed reported response rates from 13%25 to 66% (see Table 1).28 Studies surveying multiple universities reported a range of response rates from individual institutions. A technique used by one group surveying multiple schools was to set quotas for each school. This limited the upper limit of response rate by capping the number of surveys from any one institution, but also prevented overrepresentation.7,21 Several studies using data from the National College Health Assessment reported dramatic differences in response rates depending on how the survey was administered.10,19 Response rates were not reported for several studies, which makes it difficult to assess the generalizability of the survey results.11,23,30 Retention rates were also reported for studies collecting data from college students over 1 or more years.6,9,18 The 2 studies reporting retention rates had rates between 65% and 73%.9,18 Sample Diversity Most of the samples that reported fraternity and sorority smoking were characterized by low ethnic diversity 266

(see Table 1) involving predominantly white, non-Hispanic participants. Types of Fraternities and Sororities If students are members of honorary or service fraternities or sororities, this likely does not have the same association with risk behaviors as social fraternities and sororities. The majority of studies in this review did not distinguish between different types of fraternities and sororities in their sampling description. There are substantial differences in attitudes toward scholarship, service, and social activities between a “social” fraternity or sorority and one that is centered around a cultural group, service, academic affiliation/standing, or ethnic identity.31–33 For example, there is a substantial emphasis on community service and scholastic achievement in predominately African American fraternities and sororities. Although these organizations are not deemed “service” organizations, they place special emphasis on service and achievement. They also have active graduate chapters that are not merely alumni chapters, but also organized groups that still provide community service and advise the undergraduate chapters, with an emphasis on lifelong service and brotherhood/sisterhood. In contrast to other studies in this review, students from historically black colleges and universities who did not belong to a sorority or fraternity were 6.3 times more likely to smoke at least once in their life than those who were members of fraternities and sororities.30 Unlike most other studies, this study controlled for family members who smoked as well as psychosocial factors, which were only broadly described. Graduate students were also included in the sample. Graduate students have the option of continuing their active membership in many predominately African American fraternities and sororities, and thus may have influenced these results.30 Equating Fraternities and Sororities Most of the reviewed studies treated membership in a fraternity and sorority as a single variable and did not test for differences between fraternity and sorority members. However, the qualitative studies in this review15,16 suggest differences in socialization with regards to smoking for fraternity and sorority members, which may indicate that the single variable is misleading in terms of the differences that may exist between the two. Inclusion of Graduate Students Multiple studies in this review included graduate students in the sample (see Table 1),10,19,23,25,30 whereas others included a category of fifth year or greater undergraduate and graduate students that may have included students who were not eligible to be in a fraternity or sorority. Including graduate students in the sample invalidates a “no” response to the question of fraternity/sorority membership because graduate students are not eligible for membership except for cases such as predominately African American organizations. Additionally, some of the national surveys of institutions of higher JOURNAL OF AMERICAN COLLEGE HEALTH

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976 first-semester freshman at a large southwest university; 87% white; 65% responded all 3 waves 207 sorority and fraternity member smokers from a midwestern university; 94% white; retention rate not reported

Costa et al (2007)18

2,770 college students from 2 large universities; 85%–91% white; 18%–57% response rate

82,155 college students from 2008-2009 National College Health Assessment; 76% white; includes graduate students; response rate not reported

Hahn et al (2010)29

Jarrett et al (2012)23

Cronk et al (2011)6

13,041 undergraduate college students at 12 Texas 4-year colleges or universities; 74% white; 22% graduate students; 13% response rate

Study sample

Borders et al (2005)25

Authors

Type of study

Cross-sectional

Longitudinal— measured prelaw and 3.5 or 8 months postlaw

5 30-day retrospective assessments

Longitudinal study, wave 1 data examined fraternity/sorority status

Cross-sectional Web-based survey

TABLE 1. Summary of Reviewed Articles

Demographics, living on campus, alcohol use, marijuana use, other drug use, residence, international student, university and community characteristics

Smoking before and after no-smoking law passed in community, alcohol use

Social events, year in school, grades, alcohol use

Campus smoking policies, smoking prevention and education, cessation programs, changes in physical environment, roommate or friend who smokes, type of college, year in school, athlete Psychosocial and behavioral protective factors, alcohol use, marijuana use

Variables in addition to fraternity/sorority membership and basic demographics∗

How many days smoked in the last 30 in Site A. Site B never used, have used but not in last 30 days, no. of days in last 30 days How many days in the last 30 did you use ? (hookah, cigarette)

Infrequent (0–5 days), moderate (6–29 days), or daily smoker

In the past month, how many cigarettes have you smoked on an average day?

Smoked at least 1 cigarette in the last 30 days

Smoking defined as

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When comparing members of a sorority/fraternity to those that were not, members were no more likely to use cigarettes than nonmembers, but members were more likely to use hookah-only than nonmembers (odds ratio [OR] = 1.17, confidence interval [CI] [1.06, 1.29]) and members were more likely than nonmembers to be dual users (OR = 1.14, CI [1.03, 1.26]). Fraternity/sorority members were more 1.17 times more likely to be hookah only users compared to cigarette only users than nonmembers. Members were 1.14 times more likely to be dual users vs cigarette users compared to nonmembers.

85% were nondaily smokers. More cigarettes were smoked on weekends than weekdays. Smoking decreased as the semester progressed. Drinking, partying, or other social events were the most important contextual markers for smoking. Current smoking was not related to belonging to a sorority or fraternity. College student smoking was reduced following the passage of the laws.

Fraternity/sorority members were less likely to smoke after controlling for other study variables.

After controlling for other study variables, fraternity/sorority membership was not associated with higher rates of smoking.

Results relating to the relationship between fraternity/sorority membership and smoking

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267

268

Primack et al (2012)19

Powe et al (2007)30

Phua (2011)17

Nichter et al (2010)15

Nichter et al (2006)16

McCabe et al (2005)9

Authors

438 African American undergraduate and graduate college students at 8 historically black colleges and universities; 9% graduate students; response rate not reported 111,245 undergraduate and graduate students participating in the 2008–2009 National College Health Assessment; 15% graduate students; 71% white; 22%–90% response rate

10 Monitoring the Future cohorts (N = 5,883); all were full-time undergraduate students attending a 4-year college; ethnicity not reported; 73% retention rate 105 white college undergraduates from a large midwestern university 105 white college undergraduates from a large midwestern university 34 freshman fraternity members at a private 4-year university; 77% white; retention rate not reported

Study sample

Year in school, marital status, age when first smoked a cigarette, family member who smokes, cancer fatalism, cancer risk perceptions

Alcohol use, marijuana use, year in school, grade point average, relationship status, living arrangement, sexual orientation, international student, characteristics of institution

Cross-sectional survey

Cross-sectional both paper-based and online (combined in results)

Popularity, compliance with social norms, alcohol use

Partier students

Qualitative interviews and focus groups Longitudinal (followed to their senior year 2007–2010)

Partier students

Alcohol use, marijuana use, other substance use

Variables in addition to fraternity/sorority membership and basic demographics∗

Qualitative interviews and focus groups

Longitudinal, multicohort Assessed as high school seniors then at 2 and 4 years later

Type of study

TABLE 1. Summary of Reviewed Articles (Continued)

Frequency of use in the last 30 days for cigarette, cigar (and little cigar), and hookah

Smoking determined from weekly reports of smoking in another part of the study Smoking determined from weekly reports of smoking in another part of the study Current cigarette smoking, number smoked per day, intention to quit, are you more likely to smoke when hanging out with friends who smoke? Have you ever tried smoking, age when smoked a whole cigarette, ever tried to quit, do you smoke daily, smokeless tobacco use?

How frequently have you smoked in the last 30 days?

Smoking defined as

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Used cluster analysis to group students into different segments based on substance use in the last 30 days. Fraternity/sorority members were more likely to be in a cluster other than global abstainer. The risk for being classified in one of the non–general abstainer clusters was greater for fraternity/sorority members who lived in their houses than those who lived elsewhere.

Social network analysis showed the influence of fraternity smoking social norms on smoking behaviors. Popularity within the fraternity was also associated with smoking behaviors, but it was likely due to more popular members feeling more pressure to conform to social norms. Controlling for other study variables, students who did not belong to a fraternity/sorority were 6.3 times more likely to smoke at least once in their life than members of fraternities and sororities.

Focus groups and interviews revealed that fraternity/sorority members and male and female partiers have constructed different meanings and social contexts around smoking. Focus groups and interviews further described associations college students have between smoking, alcohol use, and social events.

Smoking frequency was significantly higher in high school students who later joined a fraternity or sorority than those that didn’t. Smoking frequency increased over time, but the Membership × Time interaction was not significant for smoking (it was significant for alcohol and marijuana use).

Results relating to the relationship between fraternity/sorority membership and smoking

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1,595 college students primarily freshman and sophomore intro. psych. students at a large northeastern university; 81% white; response rate not reported

82,251 undergraduates from the 2008-2009 National College Health Assessment; 73% white; 22%–90% response rate

1,102 undergraduates at 10 North Carolina colleges and universities; 87% white; 9%–34% response rate

ScottSheldon et al (2008)11

Sidani et al (2013)20

Sutfin et al (2009)21

Ridner et al (2010)26

105,012 undergraduate and graduate students from 2008–2009 National College Health Assessment; 15% graduate students; 71% white; 22%–90% response rate 741 full-time undergraduates at a large southeastern university; 84% white; 18.5% response rate

Primack et al (2013)10

Alcohol use, marijuana use, sexually transmitted diseases, sexual behaviors, eating behaviors, exercise, vigorous physical activity, hours of sleep per day Year in school, full-time, international, relationship status, sexual orientation, residence, grade point average, school characteristics, alcohol use, marijuana use

Cross-sectional

Cross-sectional

Year in school, parent education, alcohol use, marijuana use, other drug use, residence, age of smoking initiation, time after waking to first cigarette, smoking attitudes

Housing, hours worked

Cross-sectional online survey

Cross-sectional

Year in school, full/part time, international, relationship status, sexual orientation, residence, grades, institution characteristics

Cross-sectional

Number of days smoked in the last 30 days, number of cigarettes smoked on smoking days

Ever used, use in the last 30 days of cigarette, cigar/little cigar, hookah, smokeless

Self-described smoking status: smoker, social smoker, occasional, nonsmoker How many days in the last 30 days did you use cigarettes Frequency of smoking, number of cigarettes smoked per day

Number of days in the last 30 used a hookah

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Fraternity/sorority members were more likely than nonmembers to be frequent smokers rather than infrequent or nonsmokers, but fraternity/sorority members didn’t smoke more cigarettes per day than nonmembers. There was no difference for those fraternity/sorority members living in their house than those members living elsewhere. Fraternity/sorority membership and living fraternity/ sorority housing were significantly associated with each of the smoking and tobacco variables. Fraternity/sorority members had greater odds of using each substance than nonmembers. In addition, members living in fraternity/sorority housing had greater odds of using each substance than members who did not live in the fraternity/sorority house. Members of a sorority or fraternity were more likely to be social smokers and puffers than heavy and moderate smokers.

There was no significant difference in smoking rate for those belonging to fraternities and sororities (17.1%) and those that did not (17.9%).

Controlling for other study variables, fraternity/sorority members were more likely to be ever or current hookah users than nonmembers. Those living in fraternity/sorority housing were more likely to be current or ever hookah users compared to other housing options.

Smoking and Membership in a Fraternity or Sorority

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270

351 undergraduate smokers at a large midwestern university; 94% white; 66% response rate

Waters et al (2006)28

∗ Age,

ethnicity, gender.

Thompson et al (2007)27

4,100 college students using a Web-based college drinking survey; 79% white; 9%–34% response rate 14,237 college students at 30 Pacific Northwest colleges and universities; 84% white; 47% response rate

Study sample

Sutfin et al (2012)7

Authors

Cross-sectional

Cross-sectional

Cross-sectional

Type of study

TABLE 1. Summary of Reviewed Articles (Continued)

Year in school, housing, motivation to quit, self-efficacy, tobacco dependence, selfesteem, depression, social support, impulsiveness, neuroticism

Type of residence, alcohol and marijuana use, illegal drug use, multiple sex partners, parent education Year in school, residence, grade point average, college type

Variables in addition to fraternity/sorority membership and basic demographics∗

Smoking in the last 30 days, amount smoked in the past 30 days, age began smoking, nicotine dependence, change in amount of smoking since coming to college, consider self a regular smoker, desire to quit, plans to quit Days smoked in the last 30 days, number of cigarettes smoked on days smoked

Cigarette use in the last 30 days

Smoking defined as

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Fraternity/sorority members were more likely to be social smokers (31%) than other types of smokers. After controlling for other study variables, fraternity/sorority membership was not a significant predictor of social smoking.

Students living in fraternity and sorority houses were more than twice as likely (OR = 2.32) as students living in other campus residences to smoke. One in 4 (25%) fraternity/sorority members were smokers.

Nondaily smokers were 1.79 times more likely to be members of a fraternity or sorority than daily smokers (adjusted OR = 1.79, p = .04).

Results relating to the relationship between fraternity/sorority membership and smoking

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Smoking and Membership in a Fraternity or Sorority

education may not all have social fraternities and sororities. Although in these instances fraternity/sorority membership was usually a covariate and not the focus of the study, it did make it more difficult to assess the influence of fraternity/sorority membership on smoking in this review.

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Synthesis of Study Findings Patterns of Smoking in Fraternity/Sorority Members Five studies examined smoking patterns of fraternity/sorority members.6,7,11,21,28 These studies consistently showed that fraternity/sorority membership was significantly associated with social or intermittent smoking. Fraternity/sorority members were significantly more likely to smoke at least once a week than nonmembers but did not smoke more cigarettes per day than nonmembers.11 Fraternity/sorority members who kept smoking diaries showed that they were primarily nondaily smokers (86%), smoking more cigarettes on the weekends than weekdays.6 Consistent with these findings, a larger study of undergraduates from 10 colleges reported that fraternity/sorority members were 2.59 times more likely to be social smokers (smokes on weekends, 3–5 days a month) and 2.58 times more likely to be moderate smokers (smoke 10–19 days a month) than heavy smokers (daily smoker, 6–10 cigarettes a day).21 Conversely, when approaching the question of smoking and fraternity/sorority membership from the perspective of type of smoker, 2 studies found social or nondaily smokers were more likely to be members of a fraternity or sorority than other types of smokers.7,28

Other Forms of Tobacco Use Fraternity/sorority membership was significantly associated with cigarette, cigar/little cigar, hookah, and smokeless tobacco use in the last 30 days, and use rates were similar for each of the tobacco products.20 Four studies have recently shown fraternity/sorority membership was associated with current hookah use in the last 30 days and with ever use.10,19,20,23 Fraternity/sorority members were more likely to have used a hookah in the last 30 days than the general college population.19,20,23 Controlling for other study variables (see Table 1), fraternity/sorority members were 1.44 times more likely to be current hookah users and 1.45 times more likely to be ever hookah users than nonmembers.10 Small but significant effects for hookah use were evident even after controlling for alcohol, marijuana, and other drug use.23 Hookah users also tended to be younger than college students who used other substances or abstained from any substance use.19 Despite hookah’s increasing popularity fraternity/sorority members still used cigarettes, marijuana, and alcohol more often than hookah.24 It should be noted that although these studies approached the question of hookah use in fraternity and sorority members differently and controlled for different study variables, they all used the same data set. VOL 62, MAY/JUNE 2014

Smoking and Other Drug Use College students who were fraternity and sorority members engaged in a cluster of risk behaviors namely smoking, drinking, and smoking marijuana.9,11,19,24 Cigarette smoking was associated with other types of substance use, particularly alcohol and marijuana use, which were also associated with membership in a fraternity or sorority.9,11,17,19,29 In most cases, fraternity/sorority membership was no longer significantly associated with smoking after controlling for alcohol, marijuana, and other substance use.9,19,23,29 However, 2 studies did find that although the relationship between cigarette smoking and fraternity/sorority membership was no longer significant, as noted in the previous section, there were small but significant associations with hookah use even after controlling for alcohol, marijuana, and other drug use. This may indicate that hookah smoking serves a different social function for college students and may require different intervention strategies to prevent or decrease use. Selection or Socialization One debate in the literature focuses on when smoking initiation occurs in fraternity/sorority members. Do incoming college students select a particular fraternity or sorority because they are already smoking and are looking for a social environment to sustain that behavior (selection) or do new members adopt smoking behaviors of older fraternity/sorority members (socialization) after they join? One study supporting selection used longitudinal data from the Monitoring the Future study4,34 to examine 10 nationally representative cohorts. Information gathered during the senior year of high school showed that smoking was significantly higher in male and female seniors who later became fraternity/sorority members than those who chose not to join a fraternity or sorority. Two years later, there were still significant differences for these groups. Over the 4 years of the study smoking increased for college students in general, but the rate of increase in smoking was not significantly different for fraternity/sorority members and nonmembers. However, fraternity members did have the highest rates of substance use, which could be seen from their senior year of high school. Membership in a fraternity or sorority was significantly associated with the average number of cigarettes freshmen smoked each day in the last 30 days, but after risk and protective factors were taken into account (including alcohol and marijuana use), the association was small and inversely related, meaning that membership in a fraternity/sorority was associated with less smoking.18 Consistent with the previous study, researchers noted relatively stable smoking behaviors over the 2 years of the study, supporting selection. Social network analysis has been used to assess the influence of socialization on smoking in fraternity members. A small group of freshman fraternity members (n = 34) was followed through their senior year (2007–2010).17 Half of the sample were current smokers when they entered the study. Social network analysis revealed significant associations 271

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between popularity and smoking—the more popular fraternity members were within the fraternity, the more likely they were to smoke and the more likely they were to smoke more cigarettes per day than others. Smoking was associated with who fraternity members spent time with—the more time a fraternity member spent with smoking or nonsmoking members, the more likely he was to conform to that group’s social norms for smoking. Although popularity within the fraternity predicted smoking, the relationship was due to popular people conforming more to smoking social norms among fraternity members. An additional study of undergraduate smokers participating at a large midwestern university found that after controlling for psychological and physical dependence on tobacco, social support was significantly associated with social smoking in college students.28 This study also included a question about fraternity/sorority membership, which was significantly associated with social smoking, but was not reported in the final regression model. It is unclear if fraternity/sorority membership was not significantly associated with social smoking in the final model or was not included in this step of the analysis. Thus, both socialization and selection factors may be operating. The influence of living in fraternity/sorority housing may provide additional information, but it mixes selection and socialization factors, as some fraternities and sororities allow members to choose whether or not to live in their house and others require it. The Influence of Housing on Smoking Comparing members who live in fraternity/sorority housing to members who do not provides an estimate of the effect of social context on smoking behaviors. Living in the fraternity/sorority house provides a higher “dose” of socialization to fraternity/sorority culture, which we would predict to lead to higher rates of smoking. Five studies addressed where students lived during college, but the impact of living in the fraternity/sorority house was not always clear as the comparison group differed among studies.10,11,19,20,26,27 Three studies compared fraternity/sorority members who lived in the fraternity/sorority house to all other college students who lived on and off campus.10,19,27 Although this comparison does not give an indication of the difference between housing options for members and nonmembers, it does contrast extremes in fraternity/sorority socialization. A survey of students in 30 colleges and universities in the Pacific Northwest showed that students living in fraternity and sorority houses were more than twice as likely (odds ratio = 2.32) as students in campus housing to be current smokers than former or never smokers. One in 4 (26%) students living in fraternity/sorority housing were current smokers, whereas 1 in 3 (34%) identified as former smokers, and less than half (40%) were never smokers.27 Living in a fraternity or sorority house was also significantly associated with higher rates of hookah use.10 After controlling for other study variables, students living in 272

fraternity/sorority housing were 1.68 times more likely to be current hookah users than those who lived in campus residence halls. The same pattern was seen for ever use. Moreover, the risk for being categorized as a substance user was significantly greater for fraternity/sorority members who lived in fraternity/sorority housing than students living elsewhere.19 Two studies used nonresident fraternity/sorority membership as a comparison group, which provides a clearer indication of the influence of higher levels of fraternity/sorority socialization on smoking.11,20 Undergraduate responses from the 2008–2009 National College Health Assessment showed fraternity/sorority membership and living in fraternity/sorority housing were significantly associated with cigarette, cigar/little cigar, hookah, and smokeless use in the last 30 days. For each form of tobacco use, nonresident fraternity/sorority members were significantly more likely to use tobacco than nonmembers, and resident fraternity/sorority members had higher odds of use than nonresident members. Among fraternity/sorority members who lived in the fraternity/sorority house, rates of ever use were highest for binge alcohol (70%), marijuana (52%), hookah (49%), and cigarettes (47%).20 An earlier study did not find a difference for those fraternity/sorority members who lived in fraternity/sorority housing and members who lived elsewhere.11 This may have been influenced by the study sample, composed primarily of freshman and sophomore introductory psychology students. Freshmen typically do not live in the fraternity/sorority house. This study also used less sophisticated statistical analyses that did not control for other study variables, which may have influenced their findings.

The Impact of Local and Campus Policy on Smoking Three studies examined the impact of tobacco use policy on smoking and included fraternity/sorority membership as a covariate.25,29 As fraternity/sorority membership was not the focus of these studies, determining the influence of policy on fraternity/sorority smoking was not always clear. College student smoking was reduced following passage of no-smoking policies in communities surrounding 2 universities.29 Belonging to a fraternity or sorority was not significantly associated with being a current smoker after controlling for these local policies, but current alcohol use was also controlled for in the final model. College-level policies that prohibited smoking along with policies restricting sale and distribution of cigarettes were not significantly associated with student smoking rates, but clearly identified no-smoking areas and smoking prevention activities, tobacco education, and cessation classes were.25 Fraternity/sorority membership was not significantly associated with smoking after controlling for policies and other tobacco use prevention efforts, but 22% of the sample were graduate students, thus invalidating the survey question for 1 in 5 respondents. JOURNAL OF AMERICAN COLLEGE HEALTH

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In sum, local- and campus-level no-smoking policies appear to reduce smoking in the general college student population, but the data are less clear when specifically examining the impact on fraternity and sorority members. What is good for the general college student population is also likely good for fraternity/sorority members, but more research on the specific impact of campus and local community policies on fraternity/sorority smoking is needed. Exploring Social Meanings of Smoking in Fraternity and Sorority Members Two articles used qualitative methods to help explain the relationship between smoking behaviors and fraternity/sorority membership.15,16 Focus groups and interviews were conducted with college students at a large southwestern university and a midwestern university to understand smoking behaviors in 2 groups of college students, “partiers” and fraternity/sorority members. Most were current smokers. The authors discussed the results of these 2 groups together, so it was not possible to determine if all of these themes applied to fraternity and sorority members. For the purpose of this review, it was assumed that they did to some extent. Fraternity/sorority members and partiers described the role of smoking in crafting a social identity. Students made different judgments about smoking depending on the social context in which it occurred, the gender of the smoker, and the amount smoked in a particular social context. Smoking most often took place at parties, particularly at fraternity/sorority parties. Smoking was seen more negatively for females than males. Sorority and partier female smokers might be described as “trashy,” “unladylike,” “not classy,” or “uncontrolled.” This was more likely to happen if a female was seen smoking alone at a party or if students thought she smoked too much at a party. Fraternity members and male partiers did not experience the same negative evaluations about smoking—they were not expected to be as in control and a “bad boy” image was not a negative. However, like females, males were judged negatively if they were perceived to smoke too much in a particular situation, which signaled an addiction.16 College student “partiers,” including fraternity/sorority members, defined smoking at parties differently from smoking at other times. During parties, smoking was considered a part of drinking behavior. Students reported that smoking almost always followed drinking at a party, usually after several drinks.15 COMMENTS Fraternities and sororities are social networks that transmit socially normative beliefs and behaviors to their members. Fraternity and sorority members are governed by a shared set of rules that shape how members view each other and how they describe themselves. Fraternities and sororities have a social structure that provides social boundaries for attitudes, beliefs, and behaviors, but can also serve as an outlet for risk behaviors such as smoking and drinking through the partying VOL 62, MAY/JUNE 2014

culture built into the social structure of the fraternity/sorority system. Selection and Socialization Factors Previous studies found that most college student smokers (74%) started smoking before entering college.3,9,35 Similarly, studies of alcohol use show that freshmen come in to fraternities and sororities with established patterns and already higher rates of substance use.12,36 These behaviors likely influence the selection of a fraternity or sorority to support those behaviors, particularly for heavy users.12,36 This suggests that differences in rates of smoking between fraternity/sorority members and nonmembers could be in part the result of student selection into a fraternity or sorority based on alcohol and substance use during the freshman year. Researchers have argued for interventions that begin in high school, particularly for those who express an interest in joining a fraternity or sorority.1,3,9 The fraternity/sorority house is where socialization often occurs and provides the social and physical environment to support and promote unhealthy behaviors. Studies of tobacco and alcohol use show that those who live in the house have higher rates of smoking, alcohol use, and other substance use. These are often the highest on campus and higher than members who do not live in the house.12 Fraternity/sorority housing may be more attractive to those members with higher rates of unhealthy behaviors or provide a more tobacco-friendly environment for those members required to live in the house. More research is needed to understand both the selection and socialization influences on smoking in fraternities and sororities, as well as the impact of shifting smoking norms and tobacco industry marketing strategies on selection and socialization influences. Recent research with young adults has shown a shift in young adult smoking patterns, likely as a result of changing tobacco industry tactics, so that now up to 40% of young adults smokers report initiating smoking after age 17.1 Data from the American College Health Association also showed that college students estimated smoking in other students as much higher than those answering the survey, indicating a perceived social norm for college smoking and a tobacco-friendly environment even as colleges and universities are instituting smoke-free campuses.5 Smoking and Other Health Risk Behaviors Fraternity and sorority members are engaging in a variety of health risk behaviors, primarily alcohol use and smoking. There is a strong association between alcohol and nondaily smoking in college students37 and for young adults in general, regardless of college status.38 One study found that 79% of nondaily smoking in college students occurred on days when they also drank alcohol. On days where students smoke and drank, they usually smoked only after they had 2 or more alcoholic drinks.37 In support of these findings, qualitative studies revealed that college students thought of smoking as part of drinking behaviors.15,16 273

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After controlling for alcohol and marijuana use in the reviewed studies, the association between smoking and membership in a fraternity/sorority was no longer significant, suggesting that smoking’s relationship with fraternity/sorority membership was through its association with alcohol and other substance use. This is consistent with other research suggesting that tobacco use is closely tied to alcohol and to other drug use, so closely that college student smoking cannot be understood as a behavior independent of drug and alcohol use and should be studied in the context of those other health risk behaviors.1,3,9,16 These studies present an interesting opportunity for tobacco researchers to explore the reduction of college smoking by delinking smoking from alcohol consumption, or by supporting campus campaigns to reduce or eliminate alcohol consumption at campus parties. Smoking as a Social Activity but Not an Addiction Fraternity and sorority members are likely to be nondaily smokers. One explanation for this pattern is that there could be a stigma against daily smoking.7 Researchers should also consider the social acceptability of smoking when it is paired with alcohol use in social settings. This was supported by qualitative studies where smoking as part of another social activity was acceptable for partiers and fraternity/sorority members, but the appearance of addiction (of either smoking or drinking) was outside the norms of acceptable behavior. Among many young adults there has also been a redefinition of the identity of “smoker” such that college students who are party smokers do not consider themselves to be smokers.28,35 Researchers asking college students about smoking need to ask students specifically about smoking at parties and on weekends rather than using a more general query such as “are you a smoker?” Moving Beyond Cigarette Use Little cigars, cigars, and hookah are becoming more popular among college students. These were not specifically measured in most studies and those that did often found a stronger association of hookah, little cigars and cigars, and smokeless with fraternity/sorority membership than cigarette smoking, after controlling for alcohol and other drug use, which may suggest these products serve a different social or personal function among fraternity/sorority members. An emerging product among college students is ecigarettes (electronic cigarettes, also called “vaping”). Future research should monitor how e-cigarettes will be incorporated into fraternity/sorority culture. Will they also be used as a visible tool to help establish a social identity or will they serve a different function, such as transitioning to cessation as students prepare to graduate or as a substitute for cigarettes in response to campus no-smoking policies? Again, practitioners and researchers working with college students should consider how their questions about smoking address these alternate forms of smoking, particularly in more diverse groups of students where little cigars may be the primary form of tobacco use. 274

Additional Recommendations for Future Studies Local and campus no-smoking policies and the other interventions that support implementation of no-smoking policies influenced the social and physical environment surrounding college smokers, making it more difficult to smoke socially. Related studies found the number of places and situations where college students smoked was a better predictor of college student smoking 4 years later than how many of their friends smoked.8 Careful monitoring of student smoking behaviors both on and off campus, along with changing attitudes toward social smoking, will be important to supporting college leadership in instituting and maintaining these policies. It can also be utilized to assess the impact of campus no-smoking policies on perceived social norms for smoking and on the impact of these policies on incoming freshman. New policies are often supported by education, cessation, and environmental change activities.25 If this is the case, as would be anticipated in good public health practice, it will be difficult to determine if the policy change has an impact on smoking if other supporting functions were present but not assessed. Framing studies using the ecological model39 may provide better insight into multilevel influences on smoking in fraternity and sorority members. This model incorporates policy, community, organizational, interpersonal, and individual influences on smoking and how these interact with each other. Several authors have also suggested qualitative studies to understand the context of smoking.10,21 Only 1 qualitative study has been conducted with this population, combining those in fraternities/sororities with partier college students. Qualitative studies should also make a distinction between smoking in fraternity members and sorority members, as the 1 study conducted showed differences in expectations of smoking behaviors for male and female college students.

Limitations of Reviewed Studies A limitation of this review is that many of the included studies did not have fraternity/sorority membership as part of their primary research question. This limited the conclusions that could be drawn when fraternity/sorority membership was not mentioned or included in final analyses of study data. In some instances, it was difficult to determine recruitment methods, response rates, or retention rates of published studies, or they were not reported at all. Low response rates and retention rates present a threat to generalizability and interpretation of study findings. Additional threats to generalizability and interpretation of findings concerned diversity. In several instances, multiple studies used the same data set. All of the published studies that examined hookah use came from the same national survey. An additional limitation acknowledged by many of the reviewed studies was the lack of diversity among participants, who were predominantly nonHispanic white. Increasing the diversity of participants as researchers increase the diversity of samples will continue JOURNAL OF AMERICAN COLLEGE HEALTH

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to increase our understanding of the influence of fraternities and sororities on smoking in their members. Conclusions Fraternity/sorority members have higher rates of smoking and other tobacco use than nonmembers, and those that live in the fraternity/sorority house have higher rates of use than nonresident members. Fraternity/sorority members are most likely to be social or intermittent smokers, smoking most often on weekends and at parties. College students associate smoking with alcohol and other drug use. Some evidence suggests that incoming freshmen select into fraternities/sororities for atmospheres that promote or support their already established substance use behaviors that can be increased through the college and fraternity/sorority socialization processes. In several studies, the association between smoking and fraternity/sorority membership was no longer significant after controlling for alcohol and other drug use. This finding was supported by qualitative studies described the connections fraternity/sorority members made between drinking, partying, and smoking. This suggests that targeting smoking in fraternities and sororities may not be effective without also targeting its association with alcohol and other substance use. ACKNOWLEDGMENT

The authors would like to thank the Oklahoma Tobacco Research Center for their helpful advice and support. FUNDING This work was supported by the University of Oklahoma. CONFLICT OF INTEREST DISCLOSURE The authors have no conflicts of interest to report. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of the United States. The research did not require Institutional Review Board approval. NOTE For comments and further information, address correspondence to Marshall K. Cheney, Department of Health and Exercise Science, University of Oklahoma, 1401 Asp Avenue Norman, OK 73019, USA (e-mail: [email protected]). REFERENCES 1. US Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2012. 2. Ling PM, Neilands TB, Glantz SA. Young adult smoking behavior: a national study. Am J Prev Med. 2009;36:389–394. 3. Lantz PM. Smoking on the rise among young adults: implications for research and policy. Tob Control. 2003;12(suppl 1):i60–i70. 4. Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. National Survey Results on Drug Use From the Monitoring the FuVOL 62, MAY/JUNE 2014

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Received: 28 July 2013 Revised: 3 December 2013 Accepted: 3 February 2014

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