Cigar risk perceptions in focus groups of urban African American youth
Introduction
Risk perception has been shown to be an important factor in determining youth patterns of substance use (Bachman, Johnston, & O'Malley, 1998). Perception of risk is shaped by numerous factors, including personal experience, peer attitudes, education, media coverage, social factors, and communication and marketing (Douglas & Wildavsky, 1982). Changes in tobacco use practices may be related to risk perceptions or misperceptions.
Cigar smoking has recently increased among United States adults and youth Baker et al., 2000, MMWR, 1997. Over 20% of male high school students were current users of cigars (used on more than one of the past 30 days) when surveyed in 1999 (MMWR, 2000). This is troubling, because cigar smoking is known to increase risks for several cancers, including lung cancer Baker et al., 2000, Shanks & Burns, 1998. In addition, cigars may contribute to significant health problems in nonsmokers due to secondhand smoke (Repace, Ott, & Klepeis, 1998). There is also potential for development of nicotine addiction (Baker et al., 2000).
Tobacco use among African American youth has in the past been lower than among White youth (Centers for Disease Control, 1996). However, the percentage of African American male youth who report being frequent cigar users (≥50 cigars per year) is higher than that of White or Hispanic males or that of females (MMWR, 1997). In the 1999 National Youth Tobacco Survey, there was little difference in rates of current cigar use among all African American (14.8%) and White (16%) high school students, but among middle school youth, African Americans were almost twice as likely (8.8%) as White middle schoolers (4.9%) to be current cigar users (MMWR, 2000). Overall, 7.8% of middle school males and 20.3% of high school males reported current cigar use in 1999 (MMWR, 2000).
Among racial/ethnic groups, African Americans have the worst mortality from major tobacco-related diseases. For example, 81% of African American smokers who develop lung cancers die from the disease, compared to 54% of White smokers with lung cancer (U.S. Department of Health and Human Services, 1998). The leading cause of cancer deaths among African Americans in 1993 was lung cancer (U.S. Department of Health and Human Services, 1998). These worrisome findings may be related to differences in nicotine metabolism and/or differences in smoking patterns. Although African Americans are less likely to be heavy smokers than Whites, they are also less likely to quit once they begin (Novotny, Warner, Kendrick, & Remington, 1988). Recent research showed that African Americans who smoked 12 to 15 cigarettes daily had nicotine indicator levels as high as White smokers of 20 cigarettes daily (Perez-Stable, Herrera, Jacob, & Benowitz, 1998), suggesting both slower clearance and higher intake of nicotine and smoke per cigarette. African Americans are also more likely to smoke menthol and high-tar brands (Perez-Stable et al., 1998), but the exact mechanisms by which the higher nicotine levels occur remain unknown.
Given the worse health outcomes from tobacco use and differential nicotine uptake of African Americans as compared with other groups, it is particularly urgent that clinical practitioners and public health advocates understand more about the evolution of tobacco use patterns among African Americans, particularly among youth Chassin et al., 1996, U.S. Department of Health and Human Services, 1994.
Previous research Adams et al., 1999a, Adams et al., 1999b, Shopland, 1998 has established that cigar use is unhealthful, that youth are using cigars both as primary tobacco products and as vehicles for marijuana use, and that significant gaps exist in federal and state tobacco control policies related to cigars. Some of these gaps have been addressed since the study reported here was conducted. For example, the U.S. Federal Trade Commission now requires warning labels for cigars. However, there are still significant gaps in our understanding of youth cigar use, including how elements of risk are perceived and considered by youth. Developmental substance use researchers have explicitly called for multimethod approaches to learn more about how adolescents regard various substances (Johnson, Boles, Kleber, Vaughan, & McVeigh, 2000).
Youth trends change rapidly, occur in some areas before appearing in others, and may not be captured by large quantitative studies early enough to alert public health advocates to impending problems (Agar & Reisinger, 1999). Qualitative studies reveal aspects of adolescent health-risk behaviors and understandings that cannot be captured through more experience-distant methods (Rich & Ginsburg, 1999). Everyday sidewalk observations by this paper's authors revealed emerging patterns of African American youth cigar use in San Francisco and Oakland, CA during 1999. These observations, while not systematic, led to a focus group study conducted to learn more about perceptions and practices related to cigar use among these urban African American youth.
Section snippets
Methods
Six focus groups were conducted with 50 consenting urban African American participants aged 14–18 residing in San Francisco or Oakland, CA. Focus groups are moderated group interviews that generate rich descriptive data about a phenomenon Morgan, 1997, Morgan, 1998. Like other qualitative methods, they can be helpful in understanding behaviors and perceptions within social contexts or in identifying and exploring new trends Agar & Reisinger, 1999, Rich & Ginsburg, 1999.
Typically, the group is
Results
Youth positioned cigars along a continuum of risk, informed by media, school, parental, and other influences. Although 94% (44/47) of the youth responded affirmatively when asked “do you believe smoking cigars is bad for health?” on the written prediscussion questionnaire, the group dialogue revealed considerable confusion about actual risks and a “naturalness” criterion used by youth in weighing the relative risks of tobacco and other products.
Limitations
Focus groups do not provide statistically generalizable information. Their usefulness lies in their capacity for uncovering unexplored dimensions, context, and depth on an issue in the participants' own terms. The segment of African American youth who participated in our study should not be viewed as typical or as representative of all African American youth. Youth who did participate were volunteers from two local areas who specifically said they were “willing to participate in a tape-recorded
Discussion
The youth in this study, like youth everywhere, were keen observers. They had noted, for example, the lack of warning labels on cigars, the absence of cigar-specific health education in school or in the media, the use of cigars by the wealthy and successful, including rap celebrities, the relative unconcern of authority figures over cigar use, and the easy availability of cigars (including new, flavored products especially for blunts) in their own neighborhoods. Reasonably, they interpreted
Acknowledgements
This study was funded by an award from the UCSF/Mt. Zion Health Systems Cancer Center Clinical Investigator Research Program (CHR approval # H7628-15776-01). We would like to acknowledge the efforts of Annie Larson, BA for data entry and project assistance, Daniel Halperin, PhD, who consulted on study development and moderated three of the focus groups, Lynn Wenger, MSW, MPH, who assisted with data cleaning, and the participants of the Writing Seminar at the Institute for Health Policy Studies,
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