J Community Health DOI 10.1007/s10900-014-9918-7
ORIGINAL PAPER
Psychosocial Correlates of Smokeless Tobacco Use Among Indiana Adolescents Matthew Lee Smith • Brian Colwell • Chanese A. Forte´ • Jairus C. Pulczinski E. Lisako J. McKyer
•
Ó Springer Science+Business Media New York 2014
Abstract Adolescent tobacco use is influenced by intrapersonal (e.g., impulse control) and external factors, such as behaviors of friends and peers. The relationships of these factors to smokeless tobacco (ST) use are not yet fully understood. This is especially true as it pertains to the simultaneous examination of psychological and normative perceptions. Using constructs of the Biopsychosocial Model, this study investigates factors associated with lifetime ST use among middle and high school students. Data were analyzed from 938 Indiana middle and high school students. Binary sequential logistic regression was performed to examine the relationship of personal characteristics and psychosocial measures to adolescent lifetime ST use. Approximately 9 % reported having ever used ST, among which 78.6 % were male. Females and younger students were less likely to have used ST in their lifetime, whereas participants with a sibling smoker and those who compared their life to the lives of others were more likely to report lifetime ST usage. In the presence of psychological M. L. Smith (&) Department of Health Promotion and Behavior, University of Georgia College of Public Health, 330 River Road, 315 Ramsey Center, Athens, GA 30602, USA e-mail: [email protected] B. Colwell J. C. Pulczinski E. L. J. McKyer Department of Health Promotion and Community Health Sciences, Texas A&M Health Science Center School of Public Health, 1266 TAMU, College Station, TX 77843, USA C. A. Forte´ Department of Epidemiology and Biostatistics, University of Georgia College of Public Health, Athens, GA 30602, USA E. L. J. McKyer Department of Health and Kinesiology, Texas A&M University, TAMU 4243, College Station, TX 77843, USA
and normative variables, sex, age, and comparing one’s life to others remained significant. Additionally, participants who perceived higher friend approval of substance use were significantly more likely to report lifetime ST use. Understanding the normative perceptions of adolescents may lend insight into the drivers of ST use adolescent subgroups and, which may enable community and school officials to tailor interventions to prevent ST initiation and promote cessation. Keywords Smokeless tobacco Spit tobacco Adolescent Biopsychosocial
Introduction With more than twenty-five different types of smokeless tobacco (ST) available in the United States [6], the access and utilization of ST remains a public health issue among American middle and high school students. According to the Centers for Disease Control and Prevention (CDC), approximately 6.4 % of US high school students and 1.7 % of middle school students report using ST at least once in the previous 30 days [7]. When compared by sex, a substantially larger proportion of middle and high school males reported ST use relative to their female counterparts (2.2 % male compared to 1.2 % female and 11.2 % male compared to 1.5 % female, respectively) [7]. While anti-tobacco efforts fueled by evidence-based research have shown effective to reduce the prevalence of ST use among adolescents over recent decades, a modest proportion of adolescents continue to engage in this risky behavior. Given the complexities of ST use among youth, especially considering the widely known health ramifications of such behavior [19], further investigation is needed to understand the relationships between school environment, interpersonal and normative
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influences, and ST use among middle and high school students. A variety of intrapersonal factors contribute to whether or not youth will try a tobacco product while others determine whether or not they will become regular users. Among the many individual variables to be considered are impulse control, risk tolerance, and perceived mastery of the world. Developmentally, consideration must also be given to the cognitive egocentrism, including a component that involves monitoring of self and others for congruence of behavior to which youth are prone [1]. Evidence suggests ST use is greatly influenced by supportive social milieus, including school environments, family structure, and peer acceptance. In some cases, defying authorities figures who disapprove of tobacco use may give some adolescents a sense of social advantage in their peer groups, thus encouraging deviant behavior [3, 11, 12]. While peer influence is important in many youth behaviors, when investigating its association with health behavior it is important to differentiate between peer pressure as an active process and perceived social norms, which is a passive process. When thusly differentiated in previous research, perceived social norms have been identified as stronger predictors of ST use among youth than active processes [9, 13]. Students with peers and siblings who use tobacco products are much more likely to use tobacco products as well [12]. Normative influence is seen for protective behaviors, where students who participate in more physical activity tend to have more non-smoker friends and are less likely to use ST [3]. Horn et al. [13] found that youth with siblings who used ST were over four times more likely to use ST themselves, and those with friends who used ST were almost twice as likely to use, relative to youth without friends who used ST. Parental influences are also important predictors of youth tobacco use, For example, the 2012 Surgeon General’s report [23], using 2002–2007 Monitoring the Future data, indicates there is an inverse relationship between ST use and parental educational attainment among male youth. Adolescent tobacco use is influenced by intrapersonal and external factors, such as behaviors of friends and peers. However, often these influences are examined in isolation. Although these relationships between these factors have been observed in smoking behaviors, less is known about these relationships as they pertain to the use of ST among youth. Therefore, using a biopsychosocial model, this study integrates a unique constellation of variables and progressive modeling to examine the relative associations of personal and school characteristics, psychological factors, and normative beliefs on lifetime ST use.
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Methods Instrument Data were collected from participants using the Adolescent Health Risk Behavior Survey (AHRBS) instrument, which was designed from the Biopsychosocial Model [15] and intended to measure psychological and normative contributors to alcohol, tobacco, and other drug (ATOD) use of approximately 20 substances [14]. The AHRBS instrument contains 190 close-ended, Likerttype, and multiple-choice items. The 190 items are organized to form 16 distinct scales, five of which are utilized in this study. A preliminary study assessed the construct validity, internal consistency reliability, and measures of stability for data collected with the AHRBS instrument [21] using a combination of exploratory and confirmatory factor analyses and psychometric property testing procedures. Participants and Procedures After receiving Institutional Review Board approval, data were collected from 1,430 middle and high school students in one county in Southern Indiana using the AHRBS instrument. Participants were drawn from a random sample of public and private middle and high schools enrolled to participate in the Indiana Prevention Resource Center’s (IPRC) Alcohol, Tobacco, and Other Drug Use Survey [14]. A convenience sample of students present on the day of data collection was obtained from selected schools. The AHRBS instrument was administered to students in their classrooms. Uniform instructions were provided to participants prior to completing the instrument. Participation was voluntary and passive parental consent was obtained (i.e., participation was assumed unless parents actively requested that their student not participate). Of the 1,430 instruments returned, participants who did not report their lifetime ST use (n = 147) or grade level (n = 219) were omitted from analyses based on specified study aims. Additionally, participants who had missing data for study variables of interest were removed from analyses. More specifically, participants were omitted for not reporting their sex (n = 206), if they had a sibling who smoked (n = 118), if they compared themselves to others their age (n = 81), or one or more of the 20 scalerelated items used in this study (n = 211). Some participants cited more than one of these exclusionary responses, thus the final sample for this investigation included 938 students.
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Measures Dependent Variable Lifetime use of ST was used as the dependent variable for this study. Participants were asked to answer the following question: ‘‘Have you ever used snuff/smokeless tobacco?’’ Responses were scored using a 5-point Likert-type scale with categories of ‘‘never’’ (scored 0), ‘‘1–5 times’’ (scored 1), ‘‘6–19 times’’ (scored 2), ‘‘20–40 times’’ (scored 3), and ‘‘more than 40 times’’ (scored 4). Based on frequency distributions, responses were then dichotomized as ‘‘no’’ (scored 0) or ‘‘yes’’ (scored 1). Impulse Control Participants were asked to complete four items intended to measure the extent to which they had control over their impulses. For example, participants were asked to rate their level of agreement to statements like: ‘‘Even under pressure I manage to remain calm’’ and ‘‘I keep an even temper most of the time.’’ Responses were scored using a 6-point Likert-type scale with categories of ‘‘describes me very well’’ (scored 0) to ‘‘does not describe me at all’’ (scored 5). The Impulse Control Scale (ranging from 0 to 20) was created using these four items. Factor analysis with Varimax rotation was performed to generate this scale. All items loaded on one factor and the items were summed into a single composite score (a = 0. 648). Higher scores for the Impulse Control Scale indicate the participant has less control over their impulses. Mastery of the External World Participants were asked to complete three items intended to measure the extent to which they perceived mastery of their external world. For example, participants were asked to rate their level of agreement to statements like: ‘‘when I decide to do something, I do it’’ and ‘‘I feel that I am able to make decisions.’’ Responses were scored using a 6-point Likerttype scale with categories of ‘‘describes me very well’’ (scored 0) to ‘‘does not describe me at all’’ (scored 5). The Mastery of the External World Scale (ranging from 0 to 15) was created using these three items. Factor analysis with Varimax rotation was performed to generate this scale. All items loaded on one factor and the items were summed into a single composite score (a = 0. 637). Higher scores for the Mastery of the External World Scale indicate the participant perceived to have less control over the world external to them. Peer Approval Participants were asked to complete five items intended to measure the extent to which they perceived their peers would
feel about them engaging in risky behaviors. For example, participants were asked to rate their peers approval of behaviors including: ‘‘smoke one or more packs of cigarettes per day,’’ ‘‘take one or two drinks of alcohol occasionally,’’ ‘‘use marijuana daily,’’ and ‘‘use illicit drugs.’’ Responses were scored using a 5-point Likert-type scale with categories of ‘‘strongly disapprove’’ (scored 0), ‘‘disapprove’’ (scored 1), ‘‘don’t know’’ (scored 2), ‘‘approve’’ (scored 3), and ‘‘strongly approve’’ (scored 4). The Peer Approval Scale (ranging from 0 to 20) was created using these five items. Factor analysis with Varimax rotation was performed to generate this scale. All items loaded on one factor and the items were summed into a single composite score (a = 0. 910). Higher scores for the Peer Approval Scale indicate the participant perceived their peers would be more accepting of them engaging in risky behaviors. Risk Versus Benefit Scale Participants were asked to complete four items intended to measure the weight to which they perceived binge drinking, smoking cigarettes, taking methamphetamines, and using inhalants in terms of risks relative to benefits. Responses were scored using a 7-point Likert-type scale with categories of ‘‘benefits much greater than the risks’’ (scored 0) to ‘‘risks much greater than the benefits’’ (scored 6). The Risk versus Benefit Scale (ranging from 0 to 24) was created using these four items. Factor analysis with Varimax rotation was performed to generate this scale. All items loaded on one factor and the items were summed into a single composite score (a = 0. 858). Higher scores for the Risk versus Benefit Scale indicate the participant perceived these behaviors to be of more risk than benefit. Perceived Peer Behavior Participants were asked to complete four items intended to measure the extent to which they believed people their age were engaging in risky behaviors. Participants were asked to report the percentage of their peers who were: ‘‘sexually active,’’ ‘‘smoking cigarettes,’’ ‘‘drinking alcohol regularly,’’ and ‘‘using illicit drugs.’’ Responses were scored using a 6-point Likert-type scale with categories of ‘‘none’’ (scored 0), ‘‘1–20 %’’ (scored 1), ‘‘21–40 %’’ (scored 2), ‘‘41–60 %’’ (scored 3), ‘‘61–80 %’’ (scored 4), ‘‘81–100 %’’ (scored 5). The Perceived Peer Behavior Scale (ranging from 0 to 20) was created using these four items. Factor analysis with Varimax rotation was performed to generate this scale. All items loaded on one factor and the items were summed into a single composite score (a = 0. 945). Higher scores for the Perceived Peer Behavior Scale indicate the participant perceived a larger proportion of their peers to be engaging in risky behaviors.
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Personal Characteristics To identify personal characteristics of these middle and high school students, sociodemographic variables in this study included: sex, grade level (i.e., 7 through 12); and school type (i.e., private, public). Participants were also asked to report if they had a brother or sister who smoked (no, yes). Participants were asked to self-report the rate in which they compare themselves to others. Participants were asked: ‘‘How often do you compare how well things are going for you in general (socially, personally, etc.) with other people?’’ Responses were scored on a 5-point Likerttype scale with categories of ‘‘never’’ (scored 0), ‘‘rarely’’ (scored 1), ‘‘usually’’ (scored 2), ‘‘often’’ (scored 3), and ‘‘always’’ (scored 4). Based on the frequency distribution, participant responses were then dichotomized into two categories: ‘‘no’’ (scored 0; indicating they never/rarely compare themselves to others) and ‘‘yes’’ (scored 1; indicating they usually/often/always compare themselves to others). Data Analysis Tests of association between participants’ lifetime ST use status and independent variables were based on Pearson’s Chi square and t test statistics. Then, a sequential binary logistic regression was performed to determine which correlates had a statistically significant association with participants’ lifetime ST use. Within this regression, variable sets were progressively added as blocks into the model (i.e., a total of three blocks) to independently examine the unique influences of personal characteristics, intrapersonal
factors, and normative beliefs on the dependent variable. Changes in pseudo R2 values were compared between blocks within the model.
Results Sample Characteristics Sample characteristics of study participants are presented in Table 1. Of the sample respondents, approximately 9 % (n = 84) reported using ST in their lifetime, 51.8 % were female, and 75.3 % were enrolled in public schools. Generally, students were enrolled in 9th and 10th grades (3.76 ± 1.81). Over 16 % of participants reported having a sibling smoker, and 27.8 % reported comparing themselves to others in terms of how well things are going. Of the 84 participants who reported using ST in their lifetime, 66.7 % reported using ST 1–5 times, 11.9 % 6–19 times, and 21.5 % 20 or more times. When comparing study variables by the participant’s lifetime ST use status, significantly larger proportions of males (v2 = 34.12, P \ 0.001), students enrolled in public schools (v2 = 19.77, P \ 0.001), those with a sibling smoker (v2 = 4.06, P = 0.044), and those who compare themselves to others (v2 = 8.80, P = 0.003) reported using ST in their lifetime. Participants who reported using ST were enrolled in higher grade levels (t = -4.78, P \ 0.001), reported significantly lower Risk versus Benefit Scale scores (t = 4.69, P \ 0.001) and significantly higher Peer Approval Scale (t = -7.55, P \ 0.001) and Perceived Peer Behavior Scale (t = -6.27, P \ 0.001) scores.
Table 1 Sample characteristics by lifetime ST use Total (n = 938)
Never used (n = 854)
Used (n = 84)
v2 or t
P
34.12
\0.001
-4.78 19.77
\0.001 \0.001
4.06
0.044
8.80
0.003
Male
48.2 %
45.2 %
78.6 %
Female
51.8 %
54.8 %
21.4 %
Grade level (7 through 12) School type: private
3.76 (±1.81) 24.7 %
3.68 (±1.82) 26.7 %
4.66 (±1.49) 4.8 %
School type: public
75.3 %
73.3 %
95.2 %
Has sibling smoker: no
83.9 %
84.7 %
76.2 %
Has sibling smoker: yes
16.1 %
15.3 %
23.8 %
Compare self to others: no
72.2 %
73.5 %
58.3 %
Compare self to others: yes
27.8 %
26.5 %
41.7 %
Impulse Control Scale
6.72 (±3.41)
6.71 (±3.34)
6.89 (±4.04)
-0.41
0.681
Mastery of the External World Scale
3.48 (±2.62)
3.49 (±2.59)
3.37 (±2.93)
0.41
0.685
Risk versus Benefit Scale
20.79 (±4.56)
21.05 (±4.38)
18.19 (±5.41)
4.69
\0.001
Peer Approval Scale
2.49 (±3.96)
2.08 (±3.53)
6.67 (±5.46)
-7.55
\0.001
Perceived Peer Behavior Scale
3.83 (±7.58)
3.35 (±7.64)
8.68 (±4.71)
-6.27
\0.001
Means and standard deviations reported for continuous variables
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J Community Health Table 2 Factors associated with lifetime ST use among Indiana adolescents Block 1 OR
Block 2
P
95 % CI Lower
Upper
–
–
Male
1.00
Female
0.21 \0.001
0.12
0.36
Grade level (7 through 12) School type: private
1.27 1.00
1.08 –
1.49 –
1.46
12.08
4.35
–
–
1.00
School type: public
4.20
Has sibling smoker: no
1.00
Has sibling smoker: yes
1.46
Compare self to others: no
1.00
Compare self to others: yes
2.07
–
OR
0.004 – 0.008 – 0.191 –
0.83 –
0.003
1.27
2.57 – 3.38
1.00
Block 3
P
95 % CI
–
OR
Lower
Upper
–
–
1.00
0.23 \0.001
0.13
0.40
1.28 1.00
1.09 –
1.51 –
1.50
12.61
3.83
–
–
1.00
0.003 – 0.007 –
1.25 1.00
0.447 –
0.70 –
2.25 –
P
95 % CI
–
Lower
Upper
–
–
0.26 \0.001
0.14
0.47
1.18 1.00
0.99 –
1.40 –
1.31
11.15
–
–
0.060 – 0.014 –
1.09 1.00
0.770 –
0.60 –
2.01 –
1.82
0.020
1.10
3.01
1.74
0.039
1.03
2.95
1.02
0.558
0.95
1.11
1.03
0.420
0.95
1.12
Mastery of the External World Scale
0.96
0.454
0.87
1.06
0.95
0.359
0.86
1.05
Risk versus Benefit Scale
0.92 \0.001
0.88
0.96
0.95
0.060
0.91
1.00
1.14 \0.001
1.08
1.20
1.02
1.00
1.04
Impulse Control Scale
Peer Approval Scale Perceived Peer Behavior Scale Nagelkerke R2 = 0.184
Nagelkerke R2 = 0.214
0.108
Nagelkerke R2 = 0.281
Referent group: never used ST
Biopsychosocial Influences on Lifetime Smokeless Tobacco Use Lifetime Smokeless Tobacco Use The variables included in this logistic regression model were entered in three blocks. The model in Block 1 included only personal characteristics and had a Nagelkerke R-squared of 0.184. In this step, female participants were significantly less likely to have used ST in their lifetime (OR = 0.21, P \ 0.001). Participants enrolled in public schools (OR = 4.20, P = 0.008), those in higher grade levels (OR = 1.27, P = 0.004), and those who compared themselves to others (OR = 2.07, P = 0.003) were significantly more likely to use ST. The model in Block 2 encompassed the variables included in Block 1, added perceived intrapersonal variables, and had a Nagelkerke R-squared of 0.214. In this step, female participants were significantly less likely to have used ST in their lifetime (OR = 0.23, P \ 0.001); while participants enrolled in public schools (OR = 4.35, P = 0.007), those in higher grade levels (OR = 1.28, P = 0.003), and those who compared themselves to others (OR = 1.82, P = 0.003) were significantly more likely to use ST. Further, for each point higher on the Risk versus Benefit Scale, participants were significantly less likely to use ST in their lifetime (OR = 0.92, P \ 0.001). The model in Block 3 encompassed the variables included in Blocks 1 and 2, added normative belief
variables, and had a Nagelkerke R-squared of 0.281. In this step, female participants were significantly less likely to have used ST in their lifetime (OR = 0.26, P \ 0.001); and participants enrolled in public schools (OR = 3.83, P = 0.014) and those who compared themselves to others (OR = 1.74, P = 0.039) were significantly more likely to use ST. Further, for each point higher on the Peer Approval Scale, participants were significantly more likely to use ST in their lifetime (OR = 1.14, P \ 0.001; Table 2).
Discussion This study examined intrapersonal and normative influence on lifetime ST use among a sample of Indiana middle and high school students. Utilizing the Biopsychosocial Model, variables were progressively entered in blocks representing personal characteristics, intrapersonal factors, and normative beliefs, respectively. Across all model blocks, findings indicate that females were significantly less likely to use ST in their lifetime, which is supported by national trends [7]. When psychological variables were added to demographics in the regression analyses (Block 2), lower perceptions of risk associated with substance use was significantly related to lifetime ST use. However, this relationship was no longer significant when normative belief variables were added to the model (Block 3). In the full regression model (Block 3), perceived peer approval of substance use and susceptibility to conform to negative
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behaviors of peers were significantly associated with lifetime ST use. Further, students who reported comparing themselves to others was associated with ST use, which is similar to findings in alcohol-related studies of youth that identify students who frequently compare their circumstances to those of others reporting higher use patterns [8]. While multivariate, ecological studies of this nature are uncommon, it is important to use an ecological approach when examining youth risk factors for ST use. Biological influences on tobacco use such as age and sex are wellknown but uncontrollable. The behaviors of family members are considerable when describing adolescent substance use [5]. Although bivariate analyses support a relationship between adolescent ST use and sibling smoking behavior, this relationship was muted when examined with other study variables in the multivariate analysis. The absence of a significant relationship may reflect imperfect measurement where sibling smoking instead of sibling ST use was used to explain participants’ ST use (i.e., sibling ST use would serve as a better predictor of modeled behavior). Further, the sex of the sibling was not ascertained, which may also justify the absence of a significant relationship because female siblings may be less likely to use tobacco (as seen in this study) and because of unknown sex-concordant influences. Nevertheless, any tobacco use by parents, siblings, and/or peers has been shown to normalize the behavior in the observing adolescent [16]. Based on this biopsychosocial investigation, youth who perceived they have a high mastery of the external world were more likely to use ST. Amaro et al. [2] noted that adolescent girls often smoke to increase self-confidence while boys do so to cope with social insecurity. Whether this holds for ST remains to be conclusively determined. Perceiving substance use to have more risk than benefit was inversely associated with ST use among study participants. While this relationship is intuitive, significance was lost in the presence of normative factors. This finding highlights that risk awareness influences risk behavior, but the perception of peer norms and approval are most important. Conversely, this may indicate that perceived risk is a group trait that is defined by the individual in conjunction with their peers. In this study, self-monitoring with regard to others and peer approval reinforce the strength of normative influences on youth risk behavior. These findings reinforce the important role friends and peers serve in the lives of adolescents [16]. As Bandura [4] noted the interaction between the individual and his or her environment remains reciprocally deterministic [4]. While this study aimed to identify interpersonal and normative influences of ST use, the downstream reality is that tobacco use is associated with additional deviant behaviors [23]. The origins of decisions to initiate and
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sustain tobacco use are similar to those influencing youth’s decisions to engage in other risky behaviors (e.g., progressive substance use, sexual activity, crime/violence) [17]. Therefore, reducing tobacco use among middle and high school students has potential to offset, delay, or prevent delinquent behavior in their intermediate or long-term future. School-based interventions should show promise to reduce tobacco use among school-aged youth because of their ability to address individual- and peer-level factors associated with the behavior, although outcomes continue to underperform aspirations [22]. However, these interventions often occur after a youth has been caught using tobacco, thus missing the potential for preventive effects. Additionally these interventions do not and are not always capable of addressing factors external to the school environment and audiences. Therefore, studies such as this shed light on the importance of utilizing biospychosocial approaches to address upstream influences on tobacco use including family structure, socioeconomic factors, and/or the root causes of social insecurity, low self-esteem, or the need for approval/validation. Although factors such as policy and law have not been considered here, policy interventions such as taxation and reduced access to tobacco are critical components of a community’s prevention and cessation program [18], American youth do not live in a social vacuum; peer norms and acceptance of deviant behavior are factors requiring consideration when combatting ST use among youth. While paid media are considered an essential component in community-based approaches to tobacco control [10], a collaborative approach integrating schools and other locallevel entities can help to denormalize tobacco use [20]. Multi-factorial, multi-level interventions are required to address the vast number of influences on ST use among youth [16]. While the influences of peers will never be eradicated, a more accurate representation of social norms may impact students’ intentions to experiment with ST or other substances. Limitations As with any study, there are important limitations that should be considered. First, there was considerable missing data, which could have been attributed to self-selection bias and may limit the generalizability of these findings. Second, these data were cross-sectional, which limited our ability to model predictive analyses. Third, data were selfreported and collected from students in one geographic area within a single Midwestern state. Therefore, findings may not be widely generalizable beyond this sample. Fourth, a limited set of sociodemographic variables were collected from participants that may have been helpful to contextualize findings and explain ST use among this
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sample (e.g., race/ethnicity, household income). Fifth, a better measure of ST use could have been utilized to examine the frequency and duration of ST use. Further, other measures assessing familial and sibling behavior were unavailable, thus limiting our ability to identify the true influence of family on ST use within this sample.
Conclusion The factors influencing ST use among adolescents are vast and occur at many levels. Utilizing a biopsychosocial approach to examine these influences most adequately enables researchers to disentangle and contextualize these various influences and provide realistic and feasible intervention recommendations (i.e., in schools or otherwise). In this study, the role of normative factors was deemed most influential to ST use among this sample of middle and high school students. Further examination of social determinants to substance use among this subgroup is required. As an initial effort, these study findings may enable community and school officials to tailor interventions to prevent ST initiation and promote cessation.
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ORIGINAL PAPER
Psychosocial Correlates of Smokeless Tobacco Use Among Indiana Adolescents Matthew Lee Smith • Brian Colwell • Chanese A. Forte´ • Jairus C. Pulczinski E. Lisako J. McKyer
•
Ó Springer Science+Business Media New York 2014
Abstract Adolescent tobacco use is influenced by intrapersonal (e.g., impulse control) and external factors, such as behaviors of friends and peers. The relationships of these factors to smokeless tobacco (ST) use are not yet fully understood. This is especially true as it pertains to the simultaneous examination of psychological and normative perceptions. Using constructs of the Biopsychosocial Model, this study investigates factors associated with lifetime ST use among middle and high school students. Data were analyzed from 938 Indiana middle and high school students. Binary sequential logistic regression was performed to examine the relationship of personal characteristics and psychosocial measures to adolescent lifetime ST use. Approximately 9 % reported having ever used ST, among which 78.6 % were male. Females and younger students were less likely to have used ST in their lifetime, whereas participants with a sibling smoker and those who compared their life to the lives of others were more likely to report lifetime ST usage. In the presence of psychological M. L. Smith (&) Department of Health Promotion and Behavior, University of Georgia College of Public Health, 330 River Road, 315 Ramsey Center, Athens, GA 30602, USA e-mail: [email protected] B. Colwell J. C. Pulczinski E. L. J. McKyer Department of Health Promotion and Community Health Sciences, Texas A&M Health Science Center School of Public Health, 1266 TAMU, College Station, TX 77843, USA C. A. Forte´ Department of Epidemiology and Biostatistics, University of Georgia College of Public Health, Athens, GA 30602, USA E. L. J. McKyer Department of Health and Kinesiology, Texas A&M University, TAMU 4243, College Station, TX 77843, USA
and normative variables, sex, age, and comparing one’s life to others remained significant. Additionally, participants who perceived higher friend approval of substance use were significantly more likely to report lifetime ST use. Understanding the normative perceptions of adolescents may lend insight into the drivers of ST use adolescent subgroups and, which may enable community and school officials to tailor interventions to prevent ST initiation and promote cessation. Keywords Smokeless tobacco Spit tobacco Adolescent Biopsychosocial
Introduction With more than twenty-five different types of smokeless tobacco (ST) available in the United States [6], the access and utilization of ST remains a public health issue among American middle and high school students. According to the Centers for Disease Control and Prevention (CDC), approximately 6.4 % of US high school students and 1.7 % of middle school students report using ST at least once in the previous 30 days [7]. When compared by sex, a substantially larger proportion of middle and high school males reported ST use relative to their female counterparts (2.2 % male compared to 1.2 % female and 11.2 % male compared to 1.5 % female, respectively) [7]. While anti-tobacco efforts fueled by evidence-based research have shown effective to reduce the prevalence of ST use among adolescents over recent decades, a modest proportion of adolescents continue to engage in this risky behavior. Given the complexities of ST use among youth, especially considering the widely known health ramifications of such behavior [19], further investigation is needed to understand the relationships between school environment, interpersonal and normative
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influences, and ST use among middle and high school students. A variety of intrapersonal factors contribute to whether or not youth will try a tobacco product while others determine whether or not they will become regular users. Among the many individual variables to be considered are impulse control, risk tolerance, and perceived mastery of the world. Developmentally, consideration must also be given to the cognitive egocentrism, including a component that involves monitoring of self and others for congruence of behavior to which youth are prone [1]. Evidence suggests ST use is greatly influenced by supportive social milieus, including school environments, family structure, and peer acceptance. In some cases, defying authorities figures who disapprove of tobacco use may give some adolescents a sense of social advantage in their peer groups, thus encouraging deviant behavior [3, 11, 12]. While peer influence is important in many youth behaviors, when investigating its association with health behavior it is important to differentiate between peer pressure as an active process and perceived social norms, which is a passive process. When thusly differentiated in previous research, perceived social norms have been identified as stronger predictors of ST use among youth than active processes [9, 13]. Students with peers and siblings who use tobacco products are much more likely to use tobacco products as well [12]. Normative influence is seen for protective behaviors, where students who participate in more physical activity tend to have more non-smoker friends and are less likely to use ST [3]. Horn et al. [13] found that youth with siblings who used ST were over four times more likely to use ST themselves, and those with friends who used ST were almost twice as likely to use, relative to youth without friends who used ST. Parental influences are also important predictors of youth tobacco use, For example, the 2012 Surgeon General’s report [23], using 2002–2007 Monitoring the Future data, indicates there is an inverse relationship between ST use and parental educational attainment among male youth. Adolescent tobacco use is influenced by intrapersonal and external factors, such as behaviors of friends and peers. However, often these influences are examined in isolation. Although these relationships between these factors have been observed in smoking behaviors, less is known about these relationships as they pertain to the use of ST among youth. Therefore, using a biopsychosocial model, this study integrates a unique constellation of variables and progressive modeling to examine the relative associations of personal and school characteristics, psychological factors, and normative beliefs on lifetime ST use.
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Methods Instrument Data were collected from participants using the Adolescent Health Risk Behavior Survey (AHRBS) instrument, which was designed from the Biopsychosocial Model [15] and intended to measure psychological and normative contributors to alcohol, tobacco, and other drug (ATOD) use of approximately 20 substances [14]. The AHRBS instrument contains 190 close-ended, Likerttype, and multiple-choice items. The 190 items are organized to form 16 distinct scales, five of which are utilized in this study. A preliminary study assessed the construct validity, internal consistency reliability, and measures of stability for data collected with the AHRBS instrument [21] using a combination of exploratory and confirmatory factor analyses and psychometric property testing procedures. Participants and Procedures After receiving Institutional Review Board approval, data were collected from 1,430 middle and high school students in one county in Southern Indiana using the AHRBS instrument. Participants were drawn from a random sample of public and private middle and high schools enrolled to participate in the Indiana Prevention Resource Center’s (IPRC) Alcohol, Tobacco, and Other Drug Use Survey [14]. A convenience sample of students present on the day of data collection was obtained from selected schools. The AHRBS instrument was administered to students in their classrooms. Uniform instructions were provided to participants prior to completing the instrument. Participation was voluntary and passive parental consent was obtained (i.e., participation was assumed unless parents actively requested that their student not participate). Of the 1,430 instruments returned, participants who did not report their lifetime ST use (n = 147) or grade level (n = 219) were omitted from analyses based on specified study aims. Additionally, participants who had missing data for study variables of interest were removed from analyses. More specifically, participants were omitted for not reporting their sex (n = 206), if they had a sibling who smoked (n = 118), if they compared themselves to others their age (n = 81), or one or more of the 20 scalerelated items used in this study (n = 211). Some participants cited more than one of these exclusionary responses, thus the final sample for this investigation included 938 students.
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Measures Dependent Variable Lifetime use of ST was used as the dependent variable for this study. Participants were asked to answer the following question: ‘‘Have you ever used snuff/smokeless tobacco?’’ Responses were scored using a 5-point Likert-type scale with categories of ‘‘never’’ (scored 0), ‘‘1–5 times’’ (scored 1), ‘‘6–19 times’’ (scored 2), ‘‘20–40 times’’ (scored 3), and ‘‘more than 40 times’’ (scored 4). Based on frequency distributions, responses were then dichotomized as ‘‘no’’ (scored 0) or ‘‘yes’’ (scored 1). Impulse Control Participants were asked to complete four items intended to measure the extent to which they had control over their impulses. For example, participants were asked to rate their level of agreement to statements like: ‘‘Even under pressure I manage to remain calm’’ and ‘‘I keep an even temper most of the time.’’ Responses were scored using a 6-point Likert-type scale with categories of ‘‘describes me very well’’ (scored 0) to ‘‘does not describe me at all’’ (scored 5). The Impulse Control Scale (ranging from 0 to 20) was created using these four items. Factor analysis with Varimax rotation was performed to generate this scale. All items loaded on one factor and the items were summed into a single composite score (a = 0. 648). Higher scores for the Impulse Control Scale indicate the participant has less control over their impulses. Mastery of the External World Participants were asked to complete three items intended to measure the extent to which they perceived mastery of their external world. For example, participants were asked to rate their level of agreement to statements like: ‘‘when I decide to do something, I do it’’ and ‘‘I feel that I am able to make decisions.’’ Responses were scored using a 6-point Likerttype scale with categories of ‘‘describes me very well’’ (scored 0) to ‘‘does not describe me at all’’ (scored 5). The Mastery of the External World Scale (ranging from 0 to 15) was created using these three items. Factor analysis with Varimax rotation was performed to generate this scale. All items loaded on one factor and the items were summed into a single composite score (a = 0. 637). Higher scores for the Mastery of the External World Scale indicate the participant perceived to have less control over the world external to them. Peer Approval Participants were asked to complete five items intended to measure the extent to which they perceived their peers would
feel about them engaging in risky behaviors. For example, participants were asked to rate their peers approval of behaviors including: ‘‘smoke one or more packs of cigarettes per day,’’ ‘‘take one or two drinks of alcohol occasionally,’’ ‘‘use marijuana daily,’’ and ‘‘use illicit drugs.’’ Responses were scored using a 5-point Likert-type scale with categories of ‘‘strongly disapprove’’ (scored 0), ‘‘disapprove’’ (scored 1), ‘‘don’t know’’ (scored 2), ‘‘approve’’ (scored 3), and ‘‘strongly approve’’ (scored 4). The Peer Approval Scale (ranging from 0 to 20) was created using these five items. Factor analysis with Varimax rotation was performed to generate this scale. All items loaded on one factor and the items were summed into a single composite score (a = 0. 910). Higher scores for the Peer Approval Scale indicate the participant perceived their peers would be more accepting of them engaging in risky behaviors. Risk Versus Benefit Scale Participants were asked to complete four items intended to measure the weight to which they perceived binge drinking, smoking cigarettes, taking methamphetamines, and using inhalants in terms of risks relative to benefits. Responses were scored using a 7-point Likert-type scale with categories of ‘‘benefits much greater than the risks’’ (scored 0) to ‘‘risks much greater than the benefits’’ (scored 6). The Risk versus Benefit Scale (ranging from 0 to 24) was created using these four items. Factor analysis with Varimax rotation was performed to generate this scale. All items loaded on one factor and the items were summed into a single composite score (a = 0. 858). Higher scores for the Risk versus Benefit Scale indicate the participant perceived these behaviors to be of more risk than benefit. Perceived Peer Behavior Participants were asked to complete four items intended to measure the extent to which they believed people their age were engaging in risky behaviors. Participants were asked to report the percentage of their peers who were: ‘‘sexually active,’’ ‘‘smoking cigarettes,’’ ‘‘drinking alcohol regularly,’’ and ‘‘using illicit drugs.’’ Responses were scored using a 6-point Likert-type scale with categories of ‘‘none’’ (scored 0), ‘‘1–20 %’’ (scored 1), ‘‘21–40 %’’ (scored 2), ‘‘41–60 %’’ (scored 3), ‘‘61–80 %’’ (scored 4), ‘‘81–100 %’’ (scored 5). The Perceived Peer Behavior Scale (ranging from 0 to 20) was created using these four items. Factor analysis with Varimax rotation was performed to generate this scale. All items loaded on one factor and the items were summed into a single composite score (a = 0. 945). Higher scores for the Perceived Peer Behavior Scale indicate the participant perceived a larger proportion of their peers to be engaging in risky behaviors.
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Personal Characteristics To identify personal characteristics of these middle and high school students, sociodemographic variables in this study included: sex, grade level (i.e., 7 through 12); and school type (i.e., private, public). Participants were also asked to report if they had a brother or sister who smoked (no, yes). Participants were asked to self-report the rate in which they compare themselves to others. Participants were asked: ‘‘How often do you compare how well things are going for you in general (socially, personally, etc.) with other people?’’ Responses were scored on a 5-point Likerttype scale with categories of ‘‘never’’ (scored 0), ‘‘rarely’’ (scored 1), ‘‘usually’’ (scored 2), ‘‘often’’ (scored 3), and ‘‘always’’ (scored 4). Based on the frequency distribution, participant responses were then dichotomized into two categories: ‘‘no’’ (scored 0; indicating they never/rarely compare themselves to others) and ‘‘yes’’ (scored 1; indicating they usually/often/always compare themselves to others). Data Analysis Tests of association between participants’ lifetime ST use status and independent variables were based on Pearson’s Chi square and t test statistics. Then, a sequential binary logistic regression was performed to determine which correlates had a statistically significant association with participants’ lifetime ST use. Within this regression, variable sets were progressively added as blocks into the model (i.e., a total of three blocks) to independently examine the unique influences of personal characteristics, intrapersonal
factors, and normative beliefs on the dependent variable. Changes in pseudo R2 values were compared between blocks within the model.
Results Sample Characteristics Sample characteristics of study participants are presented in Table 1. Of the sample respondents, approximately 9 % (n = 84) reported using ST in their lifetime, 51.8 % were female, and 75.3 % were enrolled in public schools. Generally, students were enrolled in 9th and 10th grades (3.76 ± 1.81). Over 16 % of participants reported having a sibling smoker, and 27.8 % reported comparing themselves to others in terms of how well things are going. Of the 84 participants who reported using ST in their lifetime, 66.7 % reported using ST 1–5 times, 11.9 % 6–19 times, and 21.5 % 20 or more times. When comparing study variables by the participant’s lifetime ST use status, significantly larger proportions of males (v2 = 34.12, P \ 0.001), students enrolled in public schools (v2 = 19.77, P \ 0.001), those with a sibling smoker (v2 = 4.06, P = 0.044), and those who compare themselves to others (v2 = 8.80, P = 0.003) reported using ST in their lifetime. Participants who reported using ST were enrolled in higher grade levels (t = -4.78, P \ 0.001), reported significantly lower Risk versus Benefit Scale scores (t = 4.69, P \ 0.001) and significantly higher Peer Approval Scale (t = -7.55, P \ 0.001) and Perceived Peer Behavior Scale (t = -6.27, P \ 0.001) scores.
Table 1 Sample characteristics by lifetime ST use Total (n = 938)
Never used (n = 854)
Used (n = 84)
v2 or t
P
34.12
\0.001
-4.78 19.77
\0.001 \0.001
4.06
0.044
8.80
0.003
Male
48.2 %
45.2 %
78.6 %
Female
51.8 %
54.8 %
21.4 %
Grade level (7 through 12) School type: private
3.76 (±1.81) 24.7 %
3.68 (±1.82) 26.7 %
4.66 (±1.49) 4.8 %
School type: public
75.3 %
73.3 %
95.2 %
Has sibling smoker: no
83.9 %
84.7 %
76.2 %
Has sibling smoker: yes
16.1 %
15.3 %
23.8 %
Compare self to others: no
72.2 %
73.5 %
58.3 %
Compare self to others: yes
27.8 %
26.5 %
41.7 %
Impulse Control Scale
6.72 (±3.41)
6.71 (±3.34)
6.89 (±4.04)
-0.41
0.681
Mastery of the External World Scale
3.48 (±2.62)
3.49 (±2.59)
3.37 (±2.93)
0.41
0.685
Risk versus Benefit Scale
20.79 (±4.56)
21.05 (±4.38)
18.19 (±5.41)
4.69
\0.001
Peer Approval Scale
2.49 (±3.96)
2.08 (±3.53)
6.67 (±5.46)
-7.55
\0.001
Perceived Peer Behavior Scale
3.83 (±7.58)
3.35 (±7.64)
8.68 (±4.71)
-6.27
\0.001
Means and standard deviations reported for continuous variables
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J Community Health Table 2 Factors associated with lifetime ST use among Indiana adolescents Block 1 OR
Block 2
P
95 % CI Lower
Upper
–
–
Male
1.00
Female
0.21 \0.001
0.12
0.36
Grade level (7 through 12) School type: private
1.27 1.00
1.08 –
1.49 –
1.46
12.08
4.35
–
–
1.00
School type: public
4.20
Has sibling smoker: no
1.00
Has sibling smoker: yes
1.46
Compare self to others: no
1.00
Compare self to others: yes
2.07
–
OR
0.004 – 0.008 – 0.191 –
0.83 –
0.003
1.27
2.57 – 3.38
1.00
Block 3
P
95 % CI
–
OR
Lower
Upper
–
–
1.00
0.23 \0.001
0.13
0.40
1.28 1.00
1.09 –
1.51 –
1.50
12.61
3.83
–
–
1.00
0.003 – 0.007 –
1.25 1.00
0.447 –
0.70 –
2.25 –
P
95 % CI
–
Lower
Upper
–
–
0.26 \0.001
0.14
0.47
1.18 1.00
0.99 –
1.40 –
1.31
11.15
–
–
0.060 – 0.014 –
1.09 1.00
0.770 –
0.60 –
2.01 –
1.82
0.020
1.10
3.01
1.74
0.039
1.03
2.95
1.02
0.558
0.95
1.11
1.03
0.420
0.95
1.12
Mastery of the External World Scale
0.96
0.454
0.87
1.06
0.95
0.359
0.86
1.05
Risk versus Benefit Scale
0.92 \0.001
0.88
0.96
0.95
0.060
0.91
1.00
1.14 \0.001
1.08
1.20
1.02
1.00
1.04
Impulse Control Scale
Peer Approval Scale Perceived Peer Behavior Scale Nagelkerke R2 = 0.184
Nagelkerke R2 = 0.214
0.108
Nagelkerke R2 = 0.281
Referent group: never used ST
Biopsychosocial Influences on Lifetime Smokeless Tobacco Use Lifetime Smokeless Tobacco Use The variables included in this logistic regression model were entered in three blocks. The model in Block 1 included only personal characteristics and had a Nagelkerke R-squared of 0.184. In this step, female participants were significantly less likely to have used ST in their lifetime (OR = 0.21, P \ 0.001). Participants enrolled in public schools (OR = 4.20, P = 0.008), those in higher grade levels (OR = 1.27, P = 0.004), and those who compared themselves to others (OR = 2.07, P = 0.003) were significantly more likely to use ST. The model in Block 2 encompassed the variables included in Block 1, added perceived intrapersonal variables, and had a Nagelkerke R-squared of 0.214. In this step, female participants were significantly less likely to have used ST in their lifetime (OR = 0.23, P \ 0.001); while participants enrolled in public schools (OR = 4.35, P = 0.007), those in higher grade levels (OR = 1.28, P = 0.003), and those who compared themselves to others (OR = 1.82, P = 0.003) were significantly more likely to use ST. Further, for each point higher on the Risk versus Benefit Scale, participants were significantly less likely to use ST in their lifetime (OR = 0.92, P \ 0.001). The model in Block 3 encompassed the variables included in Blocks 1 and 2, added normative belief
variables, and had a Nagelkerke R-squared of 0.281. In this step, female participants were significantly less likely to have used ST in their lifetime (OR = 0.26, P \ 0.001); and participants enrolled in public schools (OR = 3.83, P = 0.014) and those who compared themselves to others (OR = 1.74, P = 0.039) were significantly more likely to use ST. Further, for each point higher on the Peer Approval Scale, participants were significantly more likely to use ST in their lifetime (OR = 1.14, P \ 0.001; Table 2).
Discussion This study examined intrapersonal and normative influence on lifetime ST use among a sample of Indiana middle and high school students. Utilizing the Biopsychosocial Model, variables were progressively entered in blocks representing personal characteristics, intrapersonal factors, and normative beliefs, respectively. Across all model blocks, findings indicate that females were significantly less likely to use ST in their lifetime, which is supported by national trends [7]. When psychological variables were added to demographics in the regression analyses (Block 2), lower perceptions of risk associated with substance use was significantly related to lifetime ST use. However, this relationship was no longer significant when normative belief variables were added to the model (Block 3). In the full regression model (Block 3), perceived peer approval of substance use and susceptibility to conform to negative
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behaviors of peers were significantly associated with lifetime ST use. Further, students who reported comparing themselves to others was associated with ST use, which is similar to findings in alcohol-related studies of youth that identify students who frequently compare their circumstances to those of others reporting higher use patterns [8]. While multivariate, ecological studies of this nature are uncommon, it is important to use an ecological approach when examining youth risk factors for ST use. Biological influences on tobacco use such as age and sex are wellknown but uncontrollable. The behaviors of family members are considerable when describing adolescent substance use [5]. Although bivariate analyses support a relationship between adolescent ST use and sibling smoking behavior, this relationship was muted when examined with other study variables in the multivariate analysis. The absence of a significant relationship may reflect imperfect measurement where sibling smoking instead of sibling ST use was used to explain participants’ ST use (i.e., sibling ST use would serve as a better predictor of modeled behavior). Further, the sex of the sibling was not ascertained, which may also justify the absence of a significant relationship because female siblings may be less likely to use tobacco (as seen in this study) and because of unknown sex-concordant influences. Nevertheless, any tobacco use by parents, siblings, and/or peers has been shown to normalize the behavior in the observing adolescent [16]. Based on this biopsychosocial investigation, youth who perceived they have a high mastery of the external world were more likely to use ST. Amaro et al. [2] noted that adolescent girls often smoke to increase self-confidence while boys do so to cope with social insecurity. Whether this holds for ST remains to be conclusively determined. Perceiving substance use to have more risk than benefit was inversely associated with ST use among study participants. While this relationship is intuitive, significance was lost in the presence of normative factors. This finding highlights that risk awareness influences risk behavior, but the perception of peer norms and approval are most important. Conversely, this may indicate that perceived risk is a group trait that is defined by the individual in conjunction with their peers. In this study, self-monitoring with regard to others and peer approval reinforce the strength of normative influences on youth risk behavior. These findings reinforce the important role friends and peers serve in the lives of adolescents [16]. As Bandura [4] noted the interaction between the individual and his or her environment remains reciprocally deterministic [4]. While this study aimed to identify interpersonal and normative influences of ST use, the downstream reality is that tobacco use is associated with additional deviant behaviors [23]. The origins of decisions to initiate and
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sustain tobacco use are similar to those influencing youth’s decisions to engage in other risky behaviors (e.g., progressive substance use, sexual activity, crime/violence) [17]. Therefore, reducing tobacco use among middle and high school students has potential to offset, delay, or prevent delinquent behavior in their intermediate or long-term future. School-based interventions should show promise to reduce tobacco use among school-aged youth because of their ability to address individual- and peer-level factors associated with the behavior, although outcomes continue to underperform aspirations [22]. However, these interventions often occur after a youth has been caught using tobacco, thus missing the potential for preventive effects. Additionally these interventions do not and are not always capable of addressing factors external to the school environment and audiences. Therefore, studies such as this shed light on the importance of utilizing biospychosocial approaches to address upstream influences on tobacco use including family structure, socioeconomic factors, and/or the root causes of social insecurity, low self-esteem, or the need for approval/validation. Although factors such as policy and law have not been considered here, policy interventions such as taxation and reduced access to tobacco are critical components of a community’s prevention and cessation program [18], American youth do not live in a social vacuum; peer norms and acceptance of deviant behavior are factors requiring consideration when combatting ST use among youth. While paid media are considered an essential component in community-based approaches to tobacco control [10], a collaborative approach integrating schools and other locallevel entities can help to denormalize tobacco use [20]. Multi-factorial, multi-level interventions are required to address the vast number of influences on ST use among youth [16]. While the influences of peers will never be eradicated, a more accurate representation of social norms may impact students’ intentions to experiment with ST or other substances. Limitations As with any study, there are important limitations that should be considered. First, there was considerable missing data, which could have been attributed to self-selection bias and may limit the generalizability of these findings. Second, these data were cross-sectional, which limited our ability to model predictive analyses. Third, data were selfreported and collected from students in one geographic area within a single Midwestern state. Therefore, findings may not be widely generalizable beyond this sample. Fourth, a limited set of sociodemographic variables were collected from participants that may have been helpful to contextualize findings and explain ST use among this
J Community Health
sample (e.g., race/ethnicity, household income). Fifth, a better measure of ST use could have been utilized to examine the frequency and duration of ST use. Further, other measures assessing familial and sibling behavior were unavailable, thus limiting our ability to identify the true influence of family on ST use within this sample.
Conclusion The factors influencing ST use among adolescents are vast and occur at many levels. Utilizing a biopsychosocial approach to examine these influences most adequately enables researchers to disentangle and contextualize these various influences and provide realistic and feasible intervention recommendations (i.e., in schools or otherwise). In this study, the role of normative factors was deemed most influential to ST use among this sample of middle and high school students. Further examination of social determinants to substance use among this subgroup is required. As an initial effort, these study findings may enable community and school officials to tailor interventions to prevent ST initiation and promote cessation.
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