Mimi Nichter

Women and tobacco: moving from policy to action.

A gender perspective contributes to a better understanding of the epidemiological trends, social marketing strategies, economic policies, and international actions relating to women and the tobacco epidemic. Evidence is provided in this article for the negative impact of tobacco use by women and of passive smoking on the health of women and children. Use of tobacco by women is increasing and this is related to the tobacco industrys aggressive advertising, sponsorship and promotion strategies. Policy directions are proposed in this article. At all levels, a multi-pronged strategy--including changes in legislation and fiscal policies, improvements in gender-sensitive health services, and cessation programmes--should be considered. Much more gender-specific research on tobacco use is needed, particularly in developing countries. Womens empowerment and leadership should be at the centre of all tobacco control efforts and are essential for the success of national programmes and the recently introduced Framework Convention on Tobacco Control.

Gendered dimensions of smoking among college students

Ethnographic research, including interviews, focus groups, and observations were conducted to explore gendered dimensions of smoking among low level smokers, including the acceptability of smoking in different contexts; reasons for smoking; the monitoring of self and friends’ smoking; and shared smoking as a means of communicating concern and empathy. Important gendered dimensions of smoking were documented. Although males who smoked were described as looking manly, relaxed, and in control, among females, smoking was considered a behavior that made one look slutty and out of control. Young women were found to monitor their own and their friends’ smoking carefully and tended to smoke in groups to mitigate negative perceptions of smoking. Gender-specific tobacco cessation programs are warranted on college campuses.

Qualitative research: contributions to the study of drug use, drug abuse, and drug use(r)-related interventions.

This article describes how qualitative social science research has and can contribute to the emerging field of drug and alcohol studies. An eight-stage model of formative-reformative research is presented as a heuristic to outline the different ways in which qualitative research may be used to better understand micro and macro dimensions of drug use and distribution; more effectively design, monitor and evaluate drug use(r)-related interventions; and address the politics of drug/drug program representation. Tobacco is used as an exemplar to introduce the reader to the range of research issues that a qualitative researcher may focus upon during the initial stage of formative research. Ethnographic research on alcohol use among Native Americans is highlighted to illustrate the importance of closely examining ethnicity as well as class when investigating patterns of drug use. To familiarize the reader with qualitative research, we describe the range of methods commonly employed and the ways in which qualitative research may complement as well as contribute to quantitative research. In describing the later stages of the formative-reformative process, we consider both the use of qualitative research in the evaluation and critical assessment of drug use(r)-intervention programs, and the role of qualitative research in critically assessing the politics of prevention programs. Finally, we discuss the challenges faced by qualitative researchers when engaging in transdisciplinary research.

Using qualitative research to inform survey development on nicotine dependence among adolescents

Researchers interested in measuring tobacco use and dependence among youth face several formidable challenges. These challenges include: most existing measures have been developed for adult samples and may not be suitable for adolescent respondents; surveys must be relevant to different youth subcultures and to both genders; questions must be developmentally appropriate and not perceived as judgmental or condescending; and the multidimensional nature of nicotine dependence in youth must be recognized and measured. This paper demonstrates how researchers can address these challenges by using qualitative techniques to obtain information on youth tobacco consumption, and then using this information to inform the development of quantitative instruments. A case study is presented where a measure of tobacco dependence originally developed for adults is adapted for use with adolescents. A seven-step formative research process is outlined, consisting of gathering information in open-ended interviews, conducting follow-up research, modification of questionnaire items and addition of new items based on the information gathered, constructing a reliable instrument that is readable and acceptable to youth, reducing the length of this instrument without significantly hurting reliability and validity, conducting additional follow-up research involving case studies, and examining cultural differences. Following a formative research process like this one will help tobacco researchers gain a better understanding of how nicotine dependence develops.

Texting for Health: The Use of Participatory Methods to Develop Healthy Lifestyle Messages for Teens

OBJECTIVE To develop and test messages and a mobile phone delivery protocol designed to influence the nutrition and physical activity knowledge, attitudes, and behavior of adolescents. DESIGN Nine focus groups, 4 classroom discussions, and an 8-week pilot study exploring message content, format, origin, and message delivery were conducted over 12 months using a multistage, youth-participatory approach. SETTING Youth programs at 11 locations in Arizona. PARTICIPANTS Recruitment was coordinated through youth educators and leaders. Eligible teens were 12-18 years old and enrolled in youth programs between fall 2009 and 2010. PHENOMENON OF INTEREST Adolescent preferences for messages and delivery of messages. ANALYSIS Qualitative data analysis procedures to generate themes from field notes. RESULTS One hundred seventy-seven adolescents participated in focus groups (n = 59), discussions (n = 86), and a pilot study (n = 32). Youth preferred messages with an active voice that referenced teens and recommended specific, achievable behaviors; messages should come from nutrition professionals delivered as a text message, at a frequency of ≤ 2 messages/day. CONCLUSIONS AND IMPLICATIONS More than 300 messages and a delivery protocol were successfully developed and tested in partnership with adolescents. Future research should address scalability of texting interventions; explore dose associated with changes in knowledge, attitudes, and behaviors; and offer customized message subscription options.

Negative affect, stress, and smoking in college students: Unique associations independent of alcohol and marijuana use

INTRODUCTION Stress and negative affect (NA) figure prominently in theoretical models of smoking initiation, maintenance and relapse, yet few studies have examined these associations among college students. Further complicating examination of these associations, smoking often occurs in the context of other substance use (e.g., alcohol, marijuana) in college populations. Thus, it remains unclear whether stress and NA are associated with cigarette use among college students, and if so, whether these associations are evident after controlling for effects of other substance use. The goals of this study were: a) to examine whether several aspects of stress (objective events, subjective experiences) and NA (sad mood, general emotional distress) were associated with cigarette smoking among college students and b) whether associations remained after accounting for alcohol and marijuana use. SAMPLE A large sample of college freshmen (N=633) followed longitudinally over 35 weeks via internet assessments. RESULTS Results of hierarchical linear modeling demonstrated that measures of subjective stress and NA were positively related to cigarette use, whereas measures of objective stressful events were negatively related to cigarette use. When alcohol and marijuana use were added to the models, associations between smoking and stress/NA were diminished. Associations between NA and smoking remained significant; however, associations between subjective stress/stressful events and smoking were no longer significant. CONCLUSIONS This is the first study to comprehensively examine links between subjective and objective measures of stress and smoking behavior among college students while also considering the influence of other substance use. Negative affect was the most robust correlate of smoking among college students. Subjective and objective stress do not appear to be strongly associated with college smoking above and beyond alcohol and marijuana use. Stress may not be an important etiological factor for relatively low levels of cigarette use among college students. Given that relations between NA/stress and cigarette smoking were diminished when concurrent alcohol and marijuana use was considered, it is imperative for future studies of college students to consider other substance use.

Smoking Among Low-Income Pregnant Women: An Ethnographic Analysis

This article presents findings from a qualitative study of 53 low-income women who were smokers at the onset of pregnancy. Study participants were interviewed during pregnancy to document smoking trajectories and factors contributing to, or undermining, harm reduction and quit attempts. Thirty percent of women quit smoking completely, 43% engaged in sustained harm reduction, and 26% reduced their smoking levels intermittently. Case studies of women are presented to illustrate reasons for quitting, harm reduction practices, and factors influencing relapse and smoking continuation. Womens motivations to quit are highlighted. Moral identity as a mother was found to be a key motivating factor behind womens quit attempts. Future programs targeting this population would do well to acknowledge moral identity as an issue and recognize the challenges of quitting for women with limited social support and little control over their immediate environment.

Tobacco use and secondhand smoke exposure during pregnancy in low- and middle-income countries: the need for social and cultural research

Tobacco use is a leading cause of death and of poor pregnancy outcome in many countries. While tobacco use is decreasing in many high‐income countries, it is increasing in many low‐ and middle‐income countries (LMICs), where by the year 2030, 80% of deaths caused by tobacco use are expected to occur. In many LMICs, few women smoke tobacco, but strong evidence indicates this is changing; increased tobacco smoking by pregnant women will worsen pregnancy outcomes, especially in resource‐poor settings, and threatens to undermine or reverse hard‐won gains in maternal and child health. To date, little research has focused on preventing pregnant womens tobacco use and secondhand smoke (SHS) exposure in LMICs. Research on social and cultural influences on pregnant womens tobacco use will greatly facilitate the design and implementation of effective prevention programs and policies, including the adaptation of successful strategies used in high‐income countries. This paper describes pregnant womens tobacco use and SHS exposure and the social and cultural influences on pregnant womens tobacco exposure; it also presents a research agenda put forward by an international workgroup convened to make recommendations in this area.

Reading culture from tobacco advertisements in Indonesia

Background: Tobacco advertising in Indonesia is among the most aggressive and innovative in the world, and tobacco advertisements saturate the environment. Tobacco companies are politically and financially powerful in the country because they are one of the largest sources of government revenue. As a result, there are few restrictions on tobacco marketing and advertising. National surveys reveal that 62% of men and 1% to 3% of women are smokers. Over 90% of smokers smoke clove cigarettes (kretek). This paper examines the social and cultural reasons for smoking in Indonesia and discusses how the tobacco industry reads, reproduces and works with culture as a means of selling cigarettes. An analysis is provided of how kretek tobacco companies represent themselves as supporters of Indonesian national identity. This analysis is used to identify strategies to break the chains of positive association that currently support widespread smoking. Methods: Between November 2001 and March 2007, tobacco advertisements were collected from a variety of sources, including newspapers and magazines. Frequent photographic documentation was made of adverts on billboards and in magazines. Advertisements were segmented into thematic units to facilitate analysis. In all, 30 interviews were conducted with smokers to explore benefits and risks of smoking, perceptions of advertisements and brand preferences. Focus groups (n = 12) were conducted to explore and pretest counter advertisements. Results: Key themes were identified in tobacco advertisements including control of emotions, smoking to enhance masculinity and smoking as a means to uphold traditional values while simultaneously emphasising modernity and globalisation. Some kretek advertisements are comprised of indirect commentaries inviting the viewer to reflect on the political situation and one’s position in society. Conclusions: After identifying key cultural themes in cigarette advertisements, our research group is attempting to engage the tobacco industry on “cultural ground” to reduce consumption and social acceptability. To do this, we need to take back social spaces that the tobacco industry has laid claim to through advertising. Active monitoring and surveillance of tobacco advertising strategies is necessary and legislation and enforcement to curb the industry should be put in place.

Reconsidering stress and smoking: a qualitative study among college students

Background: Although it is widely acknowledged among adult smokers that increases in smoking are often precipitated by stressful events, far less attention has been given to smoking during times of stress among youth. Aims: To address this gap by drawing attention to the social utility of smoking in contexts associated with stress among college students. Design: Face-to-face semistructured interviews with college freshmen at a large midwestern university in the US. Participants: Male and female low-level smokers (n = 24), defined as those who reported regular weekday smoking (typically 3–4 cigarettes a day) and smoking at parties on weekends, were interviewed once in person. In addition, 40 brief interviews with smokers were conducted during final examination. Measurements: Interviews focused on a range of issues including current smoking behaviour and reasons for smoking. As part of the interview, students were given a deck of cards that listed a range of reasons for smoking. Participants were asked to select cards that described their smoking experience in the past 2 weeks. Those who selected cards that indicated smoking when stressed were asked to explain the reasons why they did so. Results: A review of qualitative responses reveals that smoking served multiple functions during times of stress for college students. Cigarettes are a consumption event that facilitates a brief social interaction during study times when students feel isolated from their friends. Cigarettes also serve as an idiom of distress, signalling non-verbally to others that they were stressed. Students described smoking to manage their own stress and also to help manage “second-hand stress” from their friends and classmates. Conclusions: Moving away from an individual-focused analysis of stress to a broader assessment of the social contexts of smoking provides a more nuanced account of the multifunctionalilty of cigarettes in students’ lives. Qualitative research draws attention to issues including the need for smoking and socialising during examination time, smoking as a way to take a break and refocus, notions of second-hand stress and smoking to manage social relationships.