This article was downloaded by: [Selcuk Universitesi] On: 11 February 2015, At: 14:38 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20

Cigarette Smoking Among Korean International College Students in the United States a

b

c

Jaesin Sa PhD , Dong-Chul Seo PhD , Toben F. Nelson ScD & David K. Lohrmann PhD

d

a

Department of Exercise Science , University of Maryland Eastern Shore , Princess Anne , Maryland b

College of Health Sciences , Ewha Womans University , Seoul , South Korea

c

Division of Epidemiology and Community Health , University of Minnesota , Minneapolis , Minnesota d

Department of Applied Health Science , Indiana University , Bloomington , Indiana Accepted author version posted online: 13 Aug 2013.Published online: 23 Oct 2013.

To cite this article: Jaesin Sa PhD , Dong-Chul Seo PhD , Toben F. Nelson ScD & David K. Lohrmann PhD (2013) Cigarette Smoking Among Korean International College Students in the United States, Journal of American College Health, 61:8, 454-467, DOI: 10.1080/07448481.2013.832253 To link to this article: http://dx.doi.org/10.1080/07448481.2013.832253

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JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 61, NO. 8

Major Article

Cigarette Smoking Among Korean International College Students in the United States

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Jaesin Sa, PhD; Dong-Chul Seo, PhD; Toben F. Nelson, ScD; David K. Lohrmann, PhD

Abstract. Objective and Participants: This study explored (1) the prevalence of cigarette smoking among South Korean international college students in the United States, (2) differences in smoking between on- and off-campus living arrangements, and (3) predictors of an increase in smoking over time in the United States Methods: An online survey was completed by 1,201 students at 52 4-year US universities (34% response rate). Results: The overall smoking prevalence was 43.5%. The smoking rate (29.0%) of female students was higher than that (4%) of female college students in South Korea. Sex, living place, living situation, length of stay as a student in the United States, home smoking rules, campus-wide tobacco-free policies, and levels of acculturative stress, anxiety, and depression were significantly associated with an increase in smoking (p < .05). Conclusions: Given the high smoking prevalence among the South Korean students on US college campuses, targeted prevention efforts for these students may be warranted.

targeting international college students continue to grow, research on cigarette smoking among this population has been lacking. The health behaviors of college students are important because behaviors established in the transition between adolescence and early adulthood can be consolidated into lifetime patterns and potentially affect long-term health.8,9 Despite widespread health warnings about the risks associated with cigarette use and the decrease in the social acceptability of smoking over the past decades, college years seem to be a time when many students initiate or continue to smoke cigarettes10; cigarette smoking among college students continues to be a major health problem in the United States.11–13 Cigarette smoking is a serious public health problem in South Korea.14,15 In 2008, South Korea had one of the top 20 male smoking populations in the world.16 According to the World Health Statistics,17 53.3% and 5.7% of South Korean men and women were current smokers, respectively, suggesting that female smoking is not accepted yet in South Korean society.18 In a comparison study of university students (N = 19,298) from 23 countries, South Korean male students (44%) had the second highest rate of cigarette smoking behind Portugal (47%).19 The cigarette smoking prevalence (44%) of South Korean male students was higher than that (32%) of their American male student counterparts who ranked 14th. Studies showed that peer influences,20 weight control behavior,21 depression,22 anxiety,23 and stress24,25 are significant predictors of cigarette smoking among college students. Length of stay in the United States was negatively correlated with cigarette smoking among South Korean male immigrants,26 whereas the opposite relationship was found among South Korean female immigrants.27 Smoke-free policies at workplaces28,29 or home30,31 have proved to be effective in not only decreasing smoking rates

Keywords: acculturative stress, smoking, South Korean college students, tobacco control policy

T

he United States hosts the largest number of foreign students in the world.1 The number of international students enrolled in 2- and 4-year colleges increased 28-fold between the 1948–1949 academic year and the 2010–2011 academic year, from 25,464 students to 723,277 students.2 Asian students constitute approximately two-thirds (64%) of all international students and South Korea is one of the top 3 countries of origin for international college students.3 Whereas psychological investigations1,4–7

Dr Sa is with the Department of Exercise Science at the University of Maryland Eastern Shore in Princess Anne, Maryland. Dr Seo is with the College of Health Sciences at Ewha Womans University in Seoul, South Korea. Dr Nelson is with the Division of Epidemiology and Community Health at the University of Minnesota in Minneapolis, Minnesota. Dr Lohrmann is with the Department of Applied Health Science at Indiana University in Bloomington, Indiana. Copyright © 2013 Taylor & Francis Group, LLC 454

Cigarette Smoking Among Korean International College Students

but also increasing smoking cessation rates. However, less is known about the effect of on-campus residence on cigarette consumption among the college population.32,33 The purpose of the present study was to explore (1) the prevalence of cigarette smoking among South Korean international college students in the United States, (2) differences in smoking between students living on campus and those living off campus, and (3) predictors of an increase in smoking since South Korean students began their academic study in the United States.

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METHODS Sample Considering that South Korean international college students had e-mail addresses and were widely distributed geographically,34 a cross-sectional nonexperimental design using an online survey was employed for this study. The survey instrument was constructed in English, and study procedures were approved by the Indiana University Human Subjects Committee. A director or dean of the Office of International Student Services (OISS) of the top 100 2- and 4-year colleges hosting international students, selected by the Institute of International Education,35 was contacted by e-mail to solicit participation in the online survey. A total of 52 (13 private and 39 public) 4-year universities consented to participate in the survey. After human subjects approval was obtained from the 52 schools, an invitation with the online survey link was e-mailed to the OISS database manager of the participating universities. Then, the OISS database manager sent an e-mail with the survey link to their South Korean international students using their South Korean student listserv. Students were able to complete the survey after reading the informed consent document and checking “Yes” for the informed consent statement (ie, “I freely agree to take part in this study”) on the first page. The SurveyMonkey, an online survey company, was used for survey administration and maintenance. From March to July 2009, a total of 3,561 South Korean students were invited to participate in the online survey, and 1,480 completed the survey. Two exclusion criteria were established before data analysis. First, questionnaires (n = 251) that had more than 50% of no responses to questions were removed. Second, questionnaires (n = 28) that chose the option, “I did not fill out this survey seriously. Do not use my answers in your research” were dropped. The sample size was reduced to 1,201 (response rate of 34%) by the dual procedures. The number of South Korean students at each school varied from 72 to 1,022. Measures In order to assure reliability and validity, previously validated and reliable instruments, which included the National College Health Risk Survey,36 the Behavioral Risk Factor Surveillance System questionnaire,37 the College Alcohol Study questionnaire,38 and the Acculturative Stress Scale for International Students,39 were used to develop a 33-item VOL 61, NOVEMBER/DECEMBER 2013

questionnaire for this study (see Appendix). The entire set of items was reviewed by a jury of experts to develop a questionnaire of appropriate length that would avoid fatiguing of respondents while still ensuring content validity. Ten South Korean international students (5 undergraduate and 5 graduate students) at a university in a midwestern state helped with the development and pilot-testing of the questionnaire. Minor modifications were made and the 10 students were not included in this study. The Centers for Disease Control and Prevention definition of current smokers (ie, ever smoked 100 cigarettes in entire life and currently smoke every day or some days)40 was used to measure current smoking. Length of stay as a student in the United States was assessed by an item that was dichotomized at the median (less than 3 years vs 3 years or longer). Acculturative stress was measured by 7 items (α = .79) from the 36-item Acculturative Stress Scale. The 7 items were chosen based on the perceived relevance to South Korean students and representativeness of the items in measuring acculturative stress as assessed by the South Korean international students who participated in the pilot-test of the instrument. Levels of acculturative stress were calculated by the sum of the scores (range = 7–35) for the 7 items. Levels of acculturative stress were classified using tertiles of the scores, the cutoffs of which were 15 and 19 in this sample. Questions about depression and anxiety over the past 2 weeks were assessed with 5 items (α = .75). Levels of anxiety and depression were calculated by the sum of the scores (range = 5–15) for the 5 items. The last option “don’t know” was not included in the scores. Levels of anxiety and depression were categorized using tertiles of the scores, the cutoffs of which were 9 and 12 in this sample. The scores for acculturative stress and anxiety and depression were skewed and violated assumptions about normal distributions. Data Analysis SPSS Windows version 20.0 (SPSS, Chicago, Illinois) was used to generate statistical results. Percentage difference z tests and cross-tabulation analyses were performed to examine statistical significance of proportional differences in smoking between students living on campus (ie, college dormitory or residence hall, fraternity or sorority house, and other university or college housing) and those living off campus (ie, off-campus house or apartment and parent or guardian’s home). Predictors of interest were dichotomized for cross-tabulation analyses. Multivariable logistic regressions were conducted to compute odds ratios and 95% confidence intervals of predictors of an increase in cigarette smoking. Chi-square significance tests were used to identify candidates for predictors for the multivariable logistic regression model. Of the 11 variables identified, 3 variables (ie, grade point average, life satisfaction, and study-related stress), having strong relationships (p < .001) with an increase in smoking and medium correlations (.30 < r < .50) with other predictors, were used as control variables. 455

Sa et al

Each predictor was tested alone with only the 3 control variables. RESULTS

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Demographic Characteristics Men constituted 52% of the participants; 48% were undergraduates, 64% were aged 18 to 28 years (M = 26, SD = 5.7), 76% were single, and 22% were married. Students in the sample represented 24 different states: 25% from the Northeast, 15% from the Midwest, 27% from the South, and 33% from the West. The median length of stay in the United States was 3.0 years (SD = 1.2); 62% of students (n = 747) lived off campus, whereas 38% (n = 454) lived on campus. Descriptive Findings The rate of having smoked more than 100 cigarettes across the lifetime among all participants was 46%. Two percent of all participants did not know or were not sure whether they have smoked more than 100 cigarettes in their lifetime. More students living off campus than on campus had smoked more than 100 cigarettes in their lifetime (Table 1). The rate of current smokers (ie, having smoked at least 100 cigarettes in their lifetime and currently smoke every day or some days) among all participants was 43.5% (n = 523). More graduate students than undergraduate students (46.1% vs 40.1%; p < .05) and more males than females (57.1% vs 29.0%; p < .001) were current smokers. Compared with those living on campus (37.7%), more students living off campus (47.1%) were current smokers (p < .01). The prevalence of daily and nondaily smoking among all participants was 32% and 56%, respectively (2% of all participants selected the response option “don’t know/not sure”). More students living off campus than on campus smoked every day, whereas more students living on campus than off campus smoked some days. Analyses limited to all current smokers indicated that the overall rate of smoking ≤ 21 pack (ie, 10 cigarettes) and > 12 per day in the past 30 days was 43% and 57%, respectively. More students living off campus than living on campus smoked > 12 pack per day in the past 30 days. Other noticeable differences emerged regarding peers with whom current smokers smoked most of the time and the place where those smokers most frequently smoked. Slightly less than half of all current smokers (47%) smoked with South Korean students most of the time. Whereas more students living on campus than living off campus smoked with American students or a combination of the 3 groups (ie, American students, South Korean students, and other international students), more students living off campus smoked alone. The most frequent smoking place among all current smokers was outside offcampus buildings (43%). More students living off campus than on campus smoked inside where they lived, whereas more students living on campus than off campus smoked outside campus buildings. In terms of home smoking rules, slightly less than half of all participants (46%) resided in a location that had a full smoking ban (ie, no smoking allowed inside their home), 16% 456

allowed smoking in some places or at some times, and 38% allowed smoking anywhere inside their home. The vast majority of the students living on campus and slightly less than one-fourth of those living off campus reported that smoking was not allowed anywhere inside their home. Conversely, more than 3 times as many students living off campus as living on campus responded that smoking was allowed in some places or at some times. Approximately 27 times more students living off campus than living on campus answered that smoking was allowed anywhere at home. As shown in Table 2, students living on campus were less likely than those living off campus to smoke every day or some days. Students living on campus were less likely to smoke every day, whereas those living off campus were more likely to smoke alone and together with South Korean and other international students. Regarding home smoking rules, students living on campus were more likely to have a full smoking ban (ie, no smoking allowed inside their home), whereas those living off campus were more likely to be allowed to smoke anywhere. No difference was found between the 2 groups of students in the number of cigarettes smoked per day in the past 30 days. With regard to changes in the number of cigarettes that all current smokers had smoked since beginning their academic study in the United States, 50% reported that their smoking increased (40% decreased and 10% no change). One-fourth of the students living on campus and slightly less than twothirds of those living off campus reported that the number of cigarettes smoked increased (Table 3). Among current smokers whose smoking increased, the primary reason for increased smoking was stress relief (52%). More students living off campus than on campus increased their smoking to relieve stress, whereas more students living on campus than off campus reported that their smoking increased to reduce body weight or to relieve homesickness. Among current smokers whose smoking decreased, the primary reason was a ban on smoking in public places (39%). Whereas more students living on campus than off campus responded that their smoking decreased because of a smoking ban and cigarette price, more students living off campus than on campus reported that their smoking decreased due to health concerns. Multivariable Analysis of Predictors of Smoking Table 4 presents the results of multivariable logistic regressions analysis for increased cigarette use among all current smokers. Current female smokers were more likely than their male counterparts to report an increase in cigarette smoking. Students living off campus were more likely than those living on campus to have an increase in smoking. Students living alone and those living with at least 1 person who drinks alcohol as well as smokes cigarettes were more likely to experience an increase in smoking than those living with at least 1 person who neither drinks alcohol nor smokes cigarettes. Male smokers who resided in the United States for 3 years or longer were less likely to have an increase in smoking than those who resided in the United States for less than JOURNAL OF AMERICAN COLLEGE HEALTH

VOL 61, NOVEMBER/DECEMBER 2013 40 57 24 61 13 48 51 12 25 2 51 11 6 73 18 2 91 6 2

111∗∗∗ 275∗ 59∗ 83 88∗ 21∗∗∗ 42 3 87∗∗∗ 18∗∗∗ 10∗∗∗ 125∗∗∗ 31 3 156∗∗∗ 11∗∗∗ 4∗∗∗

%

181∗∗ 259∗∗

n

85∗∗∗ 74∗∗∗ 193∗∗∗

178∗∗∗ 101∗∗∗ 62 4

5∗∗∗ 201∗∗∗ 7 52∗∗∗ 86∗∗∗

142 210∗

276∗∗∗ 392∗ 65∗

372∗∗ 361∗∗

n

24 21 55

51 29 18 1

1 57 2 15 24

40 60

37 53 9

50 48

%

Students living off campus (n = 747)

Note. Significant differences between students living on campus and those living off campus are denoted using asterisk marks. The percentages may not add to 100 because of no responses or rounding errors. The responses “don’t know/not sure” were not included in the analysis. aAnalysis is limited to current smokers. ∗ p < .05; ∗∗ p < .01; ∗∗∗ p < .001.

Have you smoked more than 100 cigarettes in your lifetime? Yes No Do you now smoke cigarettes? Every day Some days Not at all Number of cigarettes smoked per day in the past 30 daysa ≤1/2 pack >1/2 pack Who do you smoke with most of the time?a American students Korean students Other international students Combination of the above students I smoke alone Where do you smoke the most?a Inside where I live Outside campus buildings Outside off-campus buildings Inside a car Home smoking rules Smoking is not allowed anywhere inside my home Smoking is allowed in some places or at some times Smoking is allowed anywhere inside my home

Characteristic

Students living on campus (n = 454)

TABLE 1. Comparison of Cigarette Smoking Between Students Living on Campus and Those Living off Campus (N = 1,201)

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Cigarette Smoking Among Korean International College Students

457

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TABLE 2. Cross-tabulation Analyses With Unadjusted Odds Ratios and 95% Confidence Intervals for Predictors of Cigarette Smoking Behaviors Between Students Living on Campus (n = 454) and Those Living off Campus (n = 747)

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Predictor Do you now smoke cigarettes? Every day/Some days Not at all Do you now smoke cigarettes? Every day Some days Number of cigarettes smoked per day in the past 30 daysa ≤1/2 pack >1/2 pack Who do you smoke with most of the time?a Other students I smoke alone Who do you smoke with most of the time?a American students South Korean and other international students Home smoking rules Smoking is not allowed anywhere Smoking is allowed in some places or at sometimes Home smoking rules Smoking is not allowed anywhere Smoking is allowed anywhere

OR

95% CI

0.64∗

0.44, 0.93

0.57∗∗∗

0.44, 0.75

1.40

0.97, 2.02

2.76∗∗∗

1.60, 4.76

8.27∗∗∗

3.05, 22.4

5.82∗∗∗

3.76, 8.99

53.1∗∗∗

27.8, 101.5

Note. OR = odds ratio; CI = confidence interval. aAnalysis is limited to current smokers. ∗ p < .05; ∗∗∗ p < .001.

3 years. In contrast, female smokers who had a longer duration of residence were more likely to experience an increase in smoking than those with a shorter duration of residence. Current smokers with a high level of acculturative stress were more likely to have an increase in smoking than those with a low level of acculturative stress. Current smokers whose level of anxiety and depression was moderate or high were more likely to experience an increase in smoking than those with a low level of anxiety and depression. Current smokers living in housing where smoking is allowed in some places or at some times or smoking is allowed anywhere were more likely to experience an increase in smoking than those living in housing where smoking is not allowed anywhere. In addition, current smokers studying on campuses where a tobacco-free policy was not at all strictly enforced or where a tobacco-free policy did not exist were more likely to have an increase in smoking than those studying on campuses where a tobacco-free policy was strictly enforced. 458

COMMENT This study investigated cigarette smoking behaviors among South Korean international students attending universities in the United States. The current cigarette smoking rate (43.5%) of the South Korean students (N = 1,201) is much higher than the 2010 rates (20.1% and 16%) of US adults aged 18 to 24 years41 and US college students,42 respectively. Slightly more than half of the participants in the current study (52%) were graduate students, whereas the vast majority of the participants in the 2 US studies41,42 were undergraduate students. Given that graduate participants showed a higher smoking rate than undergraduate participants (46.1% vs 40.1%; p < .05), a greater difference might exist in the prevalence of cigarette smoking if a comparison of smoking rates between South Korean and American graduate students was conducted. The higher rate of smoking among South Korean graduate students might be due to extra stressors (eg, teaching undergraduate students and conducting research at a more independent and advanced level) that South Korean undergraduate students do not have.43 The proportion of graduate to undergraduate students in this study is similar to the ratio of international graduate to international undergraduate students in the United States,44 which verifies the representativeness of the sample in this study. Thus, it is unlikely that the finding of a high smoking rate in the study sample is affected by sample selection bias. The vast majority of the current smokers smoked with others. Only 20% of the current smokers smoked alone, a finding that is consistent with previous literature that found that most college students are social smokers who smoke mainly with others.45 More than twice as many students living off campus (62%) as living on campus (25%) reported an increase in smoking (p < .001). This might be due to the fact that many universities adopted smoke-free residence hall policies.33,46 The primary reason for increased cigarette smoking among current smokers was stress relief, which again is consistent with previous evidence that cigarette smoking among college students is strongly associated with stress.24,25 The primary reason for decreased cigarette smoking among current smokers was a smoking ban in public places, a finding that confirmed the important role of smoke-free policies in reducing cigarette consumption.28,47,48 Although the prevalence of cigarette smoking among South Korean men is among the highest worldwide,16 tobacco control policies have been meager14,49 and smoking is still allowed in public places in South Korea.15 It seems that the South Korean students who experienced a decrease in smoking modified their smoking behaviors in accordance with the stricter smoke-free policies in the United States. The second-most common reason for decreased cigarette consumption among current smokers was cigarette price. Given that the cost of a carton of cigarettes in the United States is twice as high as in South Korea50 and that young smokers are more sensitive to cigarette prices than older smokers,51 the higher cigarette price in the United States was JOURNAL OF AMERICAN COLLEGE HEALTH

Cigarette Smoking Among Korean International College Students TABLE 3. Comparison of Changes in Cigarette Smoking Among Current Smokers (n = 523) Students living on campus (n = 171)

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Characteristic Change in the number of cigarettes that you smokea Increase Decrease No change Primary reason for increased smokingb More frequent socializing occasions More friends who smoke Stress relief To reduce body weight To relieve loneliness or depression To relieve homesickness Primary reason for decreased smokingb More friends who do not smoke Cost (cigarette price) Concern about my health Smoking ban in public places A loved one persuaded me to reduce smoking Religious reasons

Students living off campus (n = 352)

n

%

n

%

43∗∗∗ 113∗∗∗ 15

25 66 9

217∗∗∗ 98∗∗∗ 37

62 28 11

14 19

11 19 56 2 6 4 3 24 26 26 6 7

6 8 15∗∗∗ 4∗∗∗c 4 5∗∗∗c

9 9 12

24 42 121∗∗∗ 4∗∗∗c 12 9∗∗∗c

2 36∗ 13∗∗∗ 56∗∗∗ 0∗∗∗c 6

2 32 12 50 0 5

3 24∗ 25∗∗∗ 26∗∗∗ 6∗∗∗c 7

Note. Significant differences between students living on campus and those living off campus are denoted using asterisk marks. The percentages may not add to 100 because of no responses or rounding errors. aRespondents were asked to report changes that they have experienced since beginning their academic study in the United States. bAnalysis is limited to respondents whose smoking increased or decreased. cDue to the small frequency, the comparisons may not be statistically reliable. ∗ p < .05; ∗∗∗ p < .001.

inversely related to smoking among the South Korean students. This finding was supported by reports from previous studies showing that increased cigarette prices both reduced cigarette consumption,52 and increased adult smokers’ willingness to quit.53 The current smoking rate (29.0%) of South Korean female international students was about 7 times higher than that (4%) of the South Korean women who participated in an international comparison study of 19,298 university students from 23 countries.19 The present study shows that current female smokers were more likely than their male counterparts to experience an increase in smoking. South Korean female international students who attend universities in the United States were more likely to smoke than female college students in South Korea. This might primarily be due to the fact that although smoking is still regarded as a male behavior in South Korean society,18 it is less of a sex issue in the United States.54 A notable relationship was found between length of stay as a student in the United States and cigarette consumption among South Korean students. Male smokers whose residency in the United States was 3 years or longer were less likely to have an increase in smoking than their counterparts. In contrast, length of stay had the opposite effect for female smokers. The sex effects of length of stay in the United States on cigarette smoking are consistent with findings in previous studies.26,27 In addition to the 3 predictors (ie, sex, VOL 61, NOVEMBER/DECEMBER 2013

living place, and length of stay), anxiety and depression were significant independent predictors of an increase in cigarette smoking among current smokers, affirming the previous findings.22,23 Limitations and Conclusions This study has limitations. It used a cross-sectional survey design, which is unsuitable for making causal inferences. Measures were determined to be of high reliability, but they were not formally validated. This limitation may have impacted study findings. The present study surveyed a sample of South Korean international college students in 24 states, so findings may not be generalizable to the students attending schools in other states. Potential for nonresponse bias existed at both the individual and the college levels. This study produced a lower response rate (34%) than the recent average response rate (40%) of Internet-based surveys via e-mail,55 although 2 procedures (ie, random drawings to win $5 Starbucks gift card and a reminder e-mail sent by the OISS database manager) were employed to increase the response rate. Part of the low response rate could be attributed to the fact that the survey was available only in English. The top 100 host universities for international students were contacted. Of these, 48 declined the request because they were unable to accommodate the enormous influx of research requests from other universities. The declines and the low response rate (34%) may have affected the results 459

460

Note. OR = odds ratio; CI = confidence interval. aAll the models were adjusted for grade point average, life satisfaction, and study-related stress. ∗ p < .05; ∗∗ p < .01; ∗∗∗ p < .001.

Sex Male Female Current living place On-campus Off-campus Description of living situation Live alone Live with at least 1 person who drinks alcohol as well as smokes cigarettes Live with at least 1 person who drinks alcohol or smokes cigarettes Live with at least 1 person who neither drinks alcohol nor smokes cigarettes Length of stay in the United States among males < 3 years ≥ 3 years Length of stay in the United States among females < 3 years ≥ 3 years Acculturative stress Low Moderate High Anxiety and depression Low Moderate High Home smoking rules Smoking is not allowed anywhere Smoking is allowed in some places or at some times Smoking is allowed anywhere Campus-wide tobacco-free policy Tobacco-free policy is strictly enforced Tobacco-free policy is not strictly enforced Tobacco-free policy is not strictly enforced at all or tobacco-free policy does not exist

Predictor Reference 1.81, 1.96 Reference 1.30, 6.77 1.48, 5.45 4.26, 6.88 1.40, 4.89 Reference Reference 0.30, 0.79 Reference 1.45, 3.49 Reference 1.13, 3.58 1.83, 4.50 Reference 1.84, 5.03 2.03, 5.62 Reference 1.97, 6.59 5.08, 13.95 Reference 0.45, 1.82 1.44, 1.93

1.0 3.11∗∗∗ 2.84∗∗ 2.39∗∗∗ 2.62∗∗ 1.0 1.0 0.65∗ 1.0 2.75∗∗ 1.0 2.01∗ 2.37∗∗∗ 1.0 3.05∗∗∗ 3.38∗∗∗ 1.0 3.60∗∗∗ 8.42∗∗∗ 1.0 1.90 1.92∗

95% CI

1.0 1.26∗

Unadjusted OR

TABLE 4. Multivariable Logistic Regression of an Increase in Cigarette Smoking Among Current Smokers (n = 523)

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1.0 1.33 1.59∗

1.0 2.28∗ 3.82∗∗∗

1.0 2.54∗∗ 1.75∗∗

1.0 1.03 1.70∗

1.0 2.66∗∗

1.0 0.67∗

1.62 1.0

1.84∗∗ 2.74∗∗∗

1.0 3.05∗∗

1.0 1.37∗

Adjusted OR

Reference 0.92, 1.92 1.21, 1.66

Reference 1.03, 5.06 1.89, 7.69

Reference 1.29, 5.00 1.81, 3.76

Reference 0.48, 2.21 1.70, 4.14

Reference 1.56, 3.57

Reference 0.34, 0.77

0.71, 3.69 Reference

1.79, 4.30 4.48, 6.18

Reference 1.50, 6.21

Reference 1.71, 2.64

95% CIa

Sa et al

JOURNAL OF AMERICAN COLLEGE HEALTH

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of the current study. This study did not establish the number of years that South Korean students had (a) lived alone or with their roommates and (b) resided in their current living place (on-campus and off-campus). The average age of the participants was older than traditional US college students because this study included both undergraduate (48%) and graduate (52%) students. Thus, caution is warranted in a possible comparison of smoking rates of this study sample with those of other populations. College years are a susceptible period in the development of risk behaviors such as smoking and drinking,10 and colleges and universities are an important site for reducing risk behaviors and delivering health promotion programs to young adults aged 18 to 24 years.8,12 Numerous approaches have been developed to discourage risk behaviors among students on college campuses.12 For example, smoking cessation and relapse-prevention programs13 and an online alcohol education program56 have been provided to college students. Despite the intensive prevention and treatment efforts, college smoking continues to be a national health priority.12,57 Given the US national impetus to reduce cigarette smoking among college students,33,42,58 consideration needs to be directed toward adoption of interventions that focus on banning smoking in public places more stringently and raising tobacco taxes. Also, consideration should be given to effective policies that focus on increasing smoke-free college campuses and smoke-free residences. A randomized trial investigating a causal link between smoke-free residences and cigarette consumption among college students is needed. Given the high cigarette smoking rate of the participants, more aggressive interventions to prevent the risk behavior are needed for South Korean international college students. Recognizing the increase in cigarette smoking among the participants, US colleges and universities whose proportion of South Korean students is high should provide culturally tailored stress management programs and implement increased health promotion efforts to help students avoid initiation of smoking. Such efforts should focus on delivery of programs to students living off campus, on problems the students encounter while adjusting to a new environment, and on stressors associated with studying in a different culture along with practice of effective skills and strategies for reducing stress and preventing cigarette smoking. Considering the higher cigarette smoking rate of students living off campus than that of those living on campus, future studies are needed to investigate factors affecting the basis of decisions leading to living off campus instead of living on campus. Thus far, numerous studies have been conducted to examine psychological problems among international college students, but little has been done to investigate health behaviors of this population. Considering this dearth of research, the present study contributes to the literature by reporting the current status of cigarette smoking of South Korean international college students in the United States; identifying changes in the risk behavior after the students began their academic study in the United States; revealing the differences in smoking between the 2 groups of students (ie, on-campus VOL 61, NOVEMBER/DECEMBER 2013

vs off-campus); and providing important implications for cigarette smoking prevention strategies that target students living off campus, taking into account varying cultural characteristics. ROLE OF FUNDING SOURCES DISCLOSURE No funding was used to support this research and/or the preparation of the manuscript. 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 and received approval from the Indiana University Human Subjects Committee. NOTE For comments and further information, address correspondence to Dong-Chul Seo, PhD, FAAHB, Professor, College of Health Sciences, Ewha Womans University, 52, Ewhayeodae-gil, Soedaemoon-gu, Seoul, 120–750, South Korea (e-mail: [email protected]). REFERENCES 1. Poyrazli S, Kavanaugh PR, Baker A, Al-Timimi N. Social support and demographic correlates of acculturative stress in international students. J Coll Couns. 2004;7:73–82. 2. Institute of International Education. International students: enrollment trends. Available at: http://www.iie.org/Research-andPublications/Open-Doors/Data/International-Students/EnrollmentTrends/1948–2011. Published 2011. Accessed December 11, 2011. 3. Institute of International Education. Open Doors 2011: Regional fact sheet: Asia. Available at: http://www.iie.org/en/ Research-and-Publications/Open-Doors/Data/Fact-Sheets-by-Regi on/∼/media/Files/Corporate/Open-Doors/Fact-Sheets-2011/Regi on/Asia%20Region%20Fact%20Sheet%202011.ashx. Published 2011. Accessed January 16, 2012. 4. Mori S. Addressing the mental health concerns of international students. J Couns Dev. 2000;78:137–144. 5. Sovic S. Coping with stress: the perspective of international students. Art Design Commun Higher Educ. 2008;61:145–158. 6. Ye J. Acculturative Stress and Use of the Internet among East Asian International Students in the United States. CyberPsychol Behav. 2005;8:154–161. 7. Yi JK, Lin GJC, Yuko K. Utilization of counseling services by international students. J Instruct Psychol. 2003;30:333–342. 8. Berg C, Klatt C, Thomas J, Ahluwalia J, An L. The relationship of field of study to current smoking status among college students. Coll Student J. 2009;43:744–754. 9. Berg C, Ling P, Guo H, et al. Using market research to understand health behaviors among colleage students. Coll Student J. 2011;45:726–737. 10. Cronk NJ, Piasecki TM. Contextual and subjective antecedents of smoking in a college student sample. Nicotine Tob Res. 2010;12:997–1004. 11. Morrell HE, Cohen LM, McChargue DE. Depression vulnerability predicts cigarette smoking among college students: gender and negative reinforcement expectancies as contributing factors. Addict Behav. 2010;35:607–611. 461

Downloaded by [Selcuk Universitesi] at 14:38 11 February 2015

Sa et al 12. Rigotti NA, Lee JE, Wechsler H. US college students’ use of tobacco products: results of a national survey. JAMA. 2000;284:699–705. 13. Ramsay J, Hoffmann A. Smoking cessation and relapse prevention among undergraduate students: a pilot demonstration project. J Am Coll Health. 2004;53:11–18. 14. Kang HY, Kim HJ, Park TK, Jee SH, Nam CM, Park HW. Economic burden of smoking in Korea. Tob Control. 2003;12:37–44. 15. Lee CY, Shin S, Lee HK, Hong YM. Validation of self-report on smoking among university students in Korea. Am J Health Behav. 2009;33:540–549. 16. Shafey O, Eriksen M, Ross H, Mackay J. The Tobacco Atlas. 3rd ed. Atlanta, GA: American Cancer Society; 2009. 17. World Health Organization. World health statistics 2011. Available at: http://www.who.int/whosis/whostat/2011/ en/index.html. Published 2011. Accessed August 3, 2011. 18. Ma GX, Shive SE, Tan Y, Toubbeh JI, Fang CY, Edwards RL. Tobacco use, secondhand smoke exposure and their related knowledge, attitudes and behaviors among Asian Americans. Addict Behav. 2005;30:725–740. 19. Steptoe A, Wardle J, Cui W, et al. An international comparison of tobacco smoking, beliefs and risk awareness in university students from 23 countries. Addiction. 2002;97:1561–1571. 20. Morrell HE, Cohen LM, Bacchi D, West J. Predictors of smoking and smokeless tobacco use in college students: a preliminary study using web-based survey methodology. J Am Coll Health. 2005;54:108–115. 21. Malinauskas BM, Raedeke TD, Aeby VG, Smith JL, Dallas MB. Dieting practices, weight perceptions, and body composition: a comparison of normal weight, overweight, and obese college females. Nutr J. 2006;5:1–8. 22. Kelley FJ, Thomas SA, Friedmann E. Health risk behaviors in smoking and non-smoking young women. J Am Acad Nurse Pract. 2003;15:179–184. 23. Cranford JA, Eisenberg D, Serras AM. Substance use behaviors, mental health problems, and use of mental health services in a probability sample of college students. Addict Behav. 2009;34:134–145. 24. Nelson MC, Lust K, Story M, Ehlinger E. Credit card debt, stress and key health risk behaviors among college students. Am J Health Promot. 2008;22:400–407. 25. Nichter M, Nitchter M, Carkoglu A. Reconsidering stress and smoking: a qualitative study among college students. Tob Control. 2007;16:211–214. 26. Juon HS, Kim M, Han H, Ryu JP, Han W. Acculturation and cigarette smoking among Korean American men. Yonsei Med J. 2003;44:875–882. 27. Song YJ, Hofstetter CR, Hovell MF, et al. Acculturation and health risk behaviors among Californians of Korean descent. Prev Med. 2004;39:147–156. 28. Bauer JE, Hyland A, Li Q, Steger C, Cummings KM. A longitudinal assessment of the impact of smoke-free worksite policies on tobacco use. Am J Public Health. 2005;95:1024–1029. 29. Dove MS, Dockery DW, Mittleman MA, et al. The impact of Massachusetts’ smoke-free workplace laws on acute myocardial infarction deaths. Am J Public Health. 2010;100: 2206–2212. 30. Pizacani BA, Martin DP, Stark MJ, Koepsell TD, Thompson B, Diehr P. A prospective study of household smoking bans and subsequent cessation related behaviour: the role of stage of change. Tob Control. 2004;13:23–28. 31. Shelley D, Nguyen N, Yerneni R, Fahs M. Tobacco use behaviors and household smoking bans among Chinese Americans. Am J Health Promot. 2008;22:168–175. 32. Williams RD, Barnes JT, Hunt BP, Winborne H. Health beliefs related to secondhand smoke and smoke-free polices in a college community. Am J Health Stud. 2011;26:152–159. 462

33. Wechsler H, Lee JE, Rigotti NA. Cigarette use by college students in smoke-free housing: results of a national study. Am J Prev Med. 2001;20:202–207. 34. Sue VM, Ritter LA. Conducting Online Surveys. Thousand Oaks, CA: Sage; 2007. 35. Institute of International Education. International students: leading institutions. Available at: http://www.iie.org/opendoors. Published 2009. Accessed January 15, 2009. 36. Centers for Disease Control and Prevention. Youth risk behavior surveillance: National College Health Risk Behavior Survey—United States, 1995. MMWR Morb Mortal Weekly Rep. 1997;46:1–64. 37. Centers for Disease Control and Prevention. 2008 Behavioral Risk Factor Surveillance System Questionnaire. Available at: http://www.cdc.gov/brfss/questionnaires/pdf-ques/2008brfss.pdf. Published 2008. Accessed October 15, 2008. 38. Wechsler H, Lee JE, Kuo M, Seibring M, Nelson TF, Lee H. Trends in college binge drinking during a period of increased prevention efforts. Findings from 4 Harvard School of Public Health College Alcohol Study surveys: 1993–2001. J Am Coll Health. 2002;50:203–217. 39. Sandhu DS, Asrabadi BR. Development of an acculturative stress scale for international students: preliminary findings. Psychol Rep. 1994;75:435–448. 40. Centers for Disease Control and Prevention. Cigarette smoking among adults—United States, 2003. MMWR Morb Mortal Weekly Rep. 2005;54:509–513. 41. Centers for Disease Control and Prevention. Vital signs: current cigarette smoking among adults aged ≥18 years— United States, 2005–2010. MMWR Morb Mortal Weekly Rep. 2011;60(35):1207–1212. 42. Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future National Survey Results on Drug Use, 1975–2010: Volume II, College Students and Adults Ages 19–50. Ann Arbor, MI: Institute for Social Research, The University of Michigan; 2011. 43. Myers-Walls JA, Frias LV, Kwon K, Ko JM, Lu T. Living life in two worlds: acculturative stress among Asian intemational graduate student parents and spouses. J Comp Fam Stud. 2011;42:455–478. 44. Institute of International Education. Open Doors 2011: international student enrollment increased by 5 percent in 2010/11. Available at: http://www.iie.org/Who-We-Are/Newsand-Events/Press-Center/Press-Releases/2011/2011-11-14-OpenDoors-International-Students. Published 2012. Accessed January 16, 2012. 45. Moran S, Wechsler H, Rigotti NA. Social smoking among US college students. Pediatrics. 2004;114:1028–1034. 46. Gerson M, Allard JL, Towvim LG. Impact of smoke-free residence hall policies: the views of administrators at 3 state universities. J Am Coll Health. 2005;54:157–165. 47. Wakefield M, Cameron M, Murphy M. Potential for smokefree policies in social venues to prevent smoking uptake and reduce relapse: a qualitative study. Health Promot Pract. 2009;10:119–127. 48. Gilpin EA, Pierce JP. The California Tobacco Control Program and potential harm reduction through reduced cigarette consumption in continuing smokers. Nicotine Tob Res. 2002;4(suppl 2):S157–S166. 49. Hughes SC, Hovell MF, Hofstetter CR, Irvin VL, Park HR, Paik HY. Home smoking policy and environmental tobacco smoke exposure among Koreans in Seoul. Tob Control. 2008;17:71–72. 50. Shafey O, Eriksen M, Ross H, Mackay J. The Tobacco Atlas. 3rd ed. Atlanta, GA: American Cancer Society; 2007. Available at: http://www.cancer.org/AboutUs/GlobalHealth/CancerandTobacco ControlResources/the-tobacco-atlas-3rd-edition. Accessed March 20, 2010. 51. Ranson MK, Jha P, Chaloupka FJ, Nguyen SN. Global and regional estimates of the effectiveness and cost-effectiveness of JOURNAL OF AMERICAN COLLEGE HEALTH

Cigarette Smoking Among Korean International College Students 56. Croom K, Lewis D, Marchell T, et al. Impact of an online alcohol education course on behavior and harm for incoming firstyear college students: short-term evaluation of a randomized trial. J Am Coll Health. 2009;57:445–454. 57. Cronk NJ, Harris KJ, Harrar SW, Conway K, Catley D, Good GE. Analysis of smoking patterns and contexts among college student smokers. Subst Use Misuse. 2011;46:1015–1022. 58. Rigotti NA, Regan S, Moran SE, Wechsler H. Students’ opinion of tobacco control policies recommended for US colleges: a national survey. Tob Control. 2003;12:251–256. Received: 3 January 2013 Revised: 25 May 2013 Accepted: 28 July 2013

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price increases and other tobacco control policies. Nicotine Tob Res. 2002;4:311–319. 52. Siahpush M, Wakefield MA, Spittal MJ, Durkin SJ, Scollo MM. Taxation reduces social disparities in adult smoking prevalence. Am J Prev Med. 2009;36:285–291. 53. Chung W, Lee S, Shin K, Lim S, Cho K. Analysis of willingness-to-quit cigarette price among Korean male adults. J Prev Med Public Health. 2008;41:136–146. 54. Zeman MV, Hiraki L, Sellers EM. Gender differences in tobacco smoking: higher relative exposure to smoke than nicotine in women. J Women Health Gender Based Med. 2002;11: 147–153. 55. Archer TM. Response rates to expect from Web-based surveys and what to do about it. J Extension. 2008;46(3):Article 3RIB3. Available at: http://www.joe.org/joe/2008june/rb3.php.

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APPENDIX. Questionnaire

1. What is your gender? Original wording: What is your sex? Source: National College Health Risk (NCHR) Survey  Female  Male 2. What is your age? Source: Behavioral Risk Factor Surveillance System (BRFSS) questionnaire ( ) years  Don’t know/Not sure 3. What is your current class standing? Original wording: What is your class standing? Source: NCHR Survey  Freshman  Sophomore  Junior  Senior  Graduate Student  Other 4. In what school are you a student? Source: Developed for this study ( ) 5. What is your current GPA? Source: Developed for this study ( )  No GPA or don’t know 6. Are you. . .? Source: BRFSS questionnaire  Married  Divorced  Widowed  Separated  Never married 7. What is the length of your stay in years as a student in the U.S.? Source: Developed for this study ( ) years 8. Where do you live? Original wording: Where do you currently live? Source: NCHR Survey  College dormitory or residence hall  Fraternity or sorority house  Other university/college housing  Off-campus house or apartment  Parent/guardian’s home  Other 9. With whom do you live? Original wording: With whom do you currently live? Source: NCHR Survey  Live alone  Live with at least one person who drinks alcohol as well as smokes cigarettes  Live with at least one person who drinks alcohol or smokes cigarettes  Live with at least one person who neither drinks alcohol nor smokes cigarettes 10. In general, how satisfied are you with your life at school in the U.S.? Original wording: In general, how satisfied are you with your life at school? Source: College Alcohol Study (CAS) questionnaire  Very satisfied  Somewhat satisfied  Somewhat dissatisfied  Very dissatisfied  Don’t know (Continued)

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APPENDIX (Continued ) 11. I feel nervous to communicate in English. Source: Acculturative Stress Scale for International Students (ASSIS)  Strongly disagree  Disagree  Not sure  Agree  Strongly agree 12. I am treated differently because of my race. Source: ASSIS  Strongly disagree  Disagree  Not sure  Agree  Strongly agree 13. I miss the people and country of my origin. Source: ASSIS  Strongly disagree  Disagree  Not sure  Agree  Strongly agree 14. Others don’t appreciate my cultural values. Source: ASSIS  Strongly disagree  Disagree  Not sure  Agree  Strongly agree 15. I feel insecure here. Source: ASSIS  Strongly disagree  Disagree  Not sure  Agree  Strongly agree 16. I feel uncomfortable to adjust to new cultural values. Source: ASSIS  Strongly disagree  Disagree  Not sure  Agree  Strongly agree 17. I feel guilty to leave my family and friends behind. Source: ASSIS  Strongly disagree  Disagree  Not sure  Agree  Strongly agree 18. How stressful are your academic studies? Source: Developed for this study  Not at all  A bit  Fairly  Very  Don’t know 19. Over the last 2 weeks, how many days have you had little interest or pleasure in doing things? Source: BRFSS questionnaire  None  1–7 days  8–14 days  Don’t know (Continued) VOL 61, NOVEMBER/DECEMBER 2013

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APPENDIX (Continued ) 20. Over the last 2 weeks, how many days have you felt down, depressed or hopeless? Source: BRFSS questionnaire  None  1–7 days  8–14 days  Don’t know 21. Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much? Source: BRFSS questionnaire  None  1–7 days  8–14 days  Don’t know 22. Over the last 2 weeks, how many days have you felt tired or had little energy? Source: BRFSS questionnaire  None  1–7 days  8–14 days  Don’t know 23. Over the last 2 weeks, how many days have you had a poor appetite or eaten too much? Source: BRFSS questionnaire  None  1–7 days  8–14 days  Don’t know 24. Have you smoked at least 100 cigarettes in your entire life? Source: BRFSS questionnaire  Yes  No  Don’t know/Not sure 25. Do you now smoke cigarettes every day, some days, or not at all? Source: BRFSS questionnaire  Every day  Some days  Not at all (Go to Question 32)  Don’t know/Not sure 26. During the past 30 days, how many cigarettes did you smoke per day? Original wording: During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day? Source: NCHR Survey  I did not smoke cigarettes during the past 30 days  Less than 1 cigarette per day  1 cigarette per day  2 to 5 cigarettes per day  6 to 10 cigarettes per day  11 to 20 cigarettes per day  More than 20 cigarettes per day 27. Who do you smoke with most of the time? Source: Developed for this study  American students  Korean students  Other international students  Combination of the above students  I smoke alone  Other 28. Where do you smoke the most? Source: Developed for this study  Inside where I live  Outside campus buildings  Outside off-campus buildings  Inside a car  Other (Continued)

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APPENDIX (Continued ) 29. Since you began your academic studies in the U.S., has the number of cigarettes that you smoke changed? Source: Developed for this study  Increase (Go to Question 30)  Decrease (Go to Question 31)  No change (Go to Question 32) 30. What is a primary reason why you have smoked more cigarettes since you began your academic studies in the U.S.? Source: Developed for this study  More frequent socializing occasions  More friends who smoke  Stress relief  To reduce body weight  To relieve loneliness or depression  To relieve homesickness  Other: 31. What is a primary reason why you have smoked fewer cigarettes since you began your academic studies in the U.S.? Source: Developed for this study  More friends who do not smoke  Cost (cigarette price)  Concern about my health  Smoking ban in public places  A loved one persuaded me to reduce smoking  Religious reasons  Other: 32. Which statement best describes the rules about smoking inside your home? Do not include decks, garages, or porches. Source: BRFSS questionnaire  Smoking is not allowed anywhere inside my home  Smoking is allowed in some places or at some times  Smoking is allowed anywhere inside my home  Don’t know/Not sure 33. In your opinion, how strongly does your school enforce its tobacco free policy? Original wording: In your opinion, how strongly does your school enforce its alcohol policy? Source: CAS  Tobacco free policy is strictly enforced  Tobacco free policy is not strictly enforced  Tobacco free policy is not strictly enforced at all  Tobacco free policy does not exist  Don’t know school’s policy

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