Evaluation of a culturally tailored smoking prevention program for Asian American Youth.

Abstract

This study evaluated the effectiveness of a culturally tailored smoking prevention program for Asian American youth (Youth-PASS). A field-tested questionnaire was used to solicit information from participants on knowledge, attitudes and behaviors associated with tobacco and tobacco use, as well as satisfaction with prevention program content and style of presentation. Pretest and posttest paired data (n = 161) were collected and analyzed. Posttest results revealed a significant increase it, mean scores for knowledge related to tobacco use (4.1, p < .05). Although a positive shift in the knowledge score from pretest to posttest was found in each participant subgroup, awareness rates varied as a function of survey questions. The posttest mean attitude score increased slightly (0.6) but significant (p = 0.007). This score was slightly higher in males (1.0) than females (0.2). A large majority of participants (90%) reported they intended to share information and experiences gained through the program with family and friends. The study revealed that behavior intention was more closely associated with attitude, rather than with knowledge change. There was a significant correlation (r = 0.31) between changes in attitude and behavior intention. About 70 percent of participants responded favorably to program content and delivery style; most contributed to enhancement g the effectiveness of the program. The second generation Youth-PASS will reflect these contributions.

INTRODUCTION

American youth represent a subset of the U.S. population that is highly susceptible to tobacco industry advertising and to peer pressure, hence are at highest risk of acquiring the smoking habit early in life and of becoming rapidly addicted to nicotine (Pierce & Gilpen, 1996). Age and early addiction to nicotine represent a critical health issue to public health officials and the agencies whose mission is to protect the health of children and adolescents. According to the results of a school-based survey of students in grades 6-12 conducted by the Centers for Disease Control and Prevention in 2000, 23% of students surveyed "currently use any form of tobacco", 18% "currently smoke cigarettes", 15% "currently use some other form of tobacco" (Centers for Disease Control and Prevention, 2000b). A report by the American Osteopathic Association (2002) noted that 3,000 young people become regular tobacco users on a daily basis, and one-third of these will die from smoking-related diseases.

Data from the Monitoring the Future Project indicated that the prevalence of cigarette smoking among high school students nationwide increased substantially during the first half of the last decade. Between 1991 and 1994, smoking among 8th graders increased from 14.3% to 18.6%, and among 10th graders, 12th graders, and college freshmen from 20.8% to 25.4%, 28.3% to 31.2%, and 9% to 12.5%, respectively, an average increase of over 3.8% for all student groups (Lloyd et al., 2002). Asian adolescent smoking behavior is also on the rise and depending on gender and ethnic subgroup, ranges from 14% to 28% (CDC, 1999, 2000a, 2000c; Chen & Hawks, 1995; Ma et al., 2003; Mermelstein, 1999; U.S. DHHS, 1998; SAMHSA, 1998; Wiecha, 1996). The male prevalence rate has been reported to be 17.9% (CDC, 2000a).

Initiation to smoking early in life and early addiction to nicotine ensures a steady flow of lifetime smokers for the cigarette industry. Nearly 90% of adult smokers in the U.S. started smoking before age 18 (Elders, Perry, Eriksen, & Giovino, 1994). Addiction to smoking and nicotine is highly unlikely among those youth who abstain from smoking while in school and who graduate without acquiring the behavior (CDC, 1994a). Many young smokers are of the opinion that smoking and nicotine are not habit forming, hence are easy to relinquish; most are unaware of the severe dependency that nicotine can engender among the young (Pierce & Gilpen, 1996).

The health risks associated with smoking among youth are well-documented and include problems that range from simple coughing and phlegm production caused by tobacco irritants, to the more serious respiratory illnesses that lead to decreased physical fitness and to structural deformities in the laryngeal and esophageal mechanisms. Because smoking is often associated with alcohol consumption and with illicit drug use, e.g., marijuana and hard drugs, the behavior exposes the young to other health risks, compounding their health problems (CDC, 1992; Little, 2000).

Asian Americans constitute one of the fastest growing ethnic-cultural groups in the U.S. today, doubling its size from 3.4 million to over 7 million between 1980 and 1990. In 2000, the Asian American population increased to 10 million, constituting 3.6% of the total U.S. population (U.S. Census Bureau, 2000a). One-third of Asian Americans are under 20 years of age (U.S. Department of Commerce, Bureau of the Census, Economic and Statistics Administration, 1999).

Social and cultural factors predispose Asian American youth to smoking and secondhand smoke. One of these factors is the continuing influx of new immigrant families from countries where tobacco use is not only condoned, but also encouraged. More than 60% of Asian American residents of the Delaware Valley Region of Pennsylvania (PA) and New Jersey (NJ) Asian population is comprised of new immigrants whose origins are in countries where more than 80% of male adults smoke (U.S. Census Bureau, 2000b). The lack of knowledge about the effect of smoking in closed environments on others is another factor that predisposes children, youth and nonsmokers to airborne tobacco chemicals, a number of which are more harmful to health when exhaled than inhaled. Our studies have shown that other socio-cultural factors also contribute to smoking behavior: for example, tobacco use increases with age and number of years of living in the U.S., both of which are related to acculturation (Ma et al., in press).

This article describes a culturally appropriate approach to smoking prevention for Asian American youth titled, "Preventing Asian Youth from Smoking and Secondhand Smoke" (Youth-PASS) and summarizes preliminary research on the effectiveness of the Youth-PASS Program in this population.

The Youth-PASS Prevention Program

The Youth-PASS prevention program was initiated in 2000 and pilot tested among five groups of over 100 Asian youth, each group comprised of about 20 participants. The aim of the program was to increase knowledge about tobacco use and change attitudes toward the hazardous consequences of smoking and secondhand smoke, as well as to expose youth to awareness of the dangers of chemicals in tobacco and tobacco smoke, the tobacco industry's targeting of Asians, and the hidden costs of cigarette consumption.

The program was designed as a school- and community-based prevention/intervention program targeting a specific set of risk factors in the youth population. The ultimate goal was to prevent the initiation of and reduction in the prevalence of tobacco use among Asian youth, especially new immigrants experiencing adjustment to their new environment in the U.S. Following the pilot tests, the curriculum, handouts and evaluation instruments were revised and reviewed by staff of the Cancer Information Service and Asian community professionals. The revised curriculum included four sessions: hazardous effects of tobacco and addiction; health consequences and impact of smoking and secondhand smoke; hidden cost of smoking; and the tobacco industry's targeting of Asian adults and youth. The training education was delivered in a one-hour period.

The program was designed for and administrated in schools with a large enrollment of Asian students, and an Asian community-based after-school program. The program is culturally appropriate for a wide range of Asian ethnic groups that include Chinese, Koreans, Cambodians, Vietnamese and others, and uses culturally tailored, multi-media strategies (posters, pictures, video, learning activities, Power Point presentation, teaching tools and materials) to accommodate the needs of these populations.

Since its initiation in 2000, the Youth-PASS program has undergone continuous modifications and improvements based on input from the Asian professional staff of the Asian Tobacco and Cancer Awareness Research Initiative (ATECAR), the Asian Community Cancer Coalition, focus groups and professional practitioners acquainted with the Asian youth. Examples of some important cultural elements incorporated into the curriculum are: reasons why Asian teens smoke; awareness of tobacco industry's marketing of tobacco products to Asian youth; use of posters, pictures, display boards symbolizing Asian images and faces; and reference to famous Asian celebrities and other role models, among others. The program is delivered by Asian peer health educators and offers a forum for discussion of tobacco issues and concerns brought up by participating youth, allowing for further interaction between youth and educators. The program also gives youth the opportunity to make appropriate choices regarding healthy lifestyles through a deeper and critical understanding of tobacco industry's subtle marketing strategies.

Theoretical Framework

ATECAR's Youth-PASS Program utilizes components of the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA) (Glanz, Lewis, & Rimer, 1997). According to the HBM, the determinants of behavior are an assessment of three proximal factors: perceptions of severity and susceptibility of the health problem and perceived susceptibility from one source of motivation to change behavior, namely, the perceived threat. Other assessments are perceived benefits of action (what will be gained) and the perceived barriers (what will be lost and the transaction costs). The latter two are weighed as some form of decisional balance and, together with perceived threat, collectively determine behavior (Glanz et al., 1997). Altering perception of a given behavior (e.g., a belief among smokers that tobacco use represents independence and maturity, or that it leads to reduction in anxiety) produces a desirable behavior change (e.g., knowledge about tobacco's adverse effect on one's health and that of others, or improved personal and family health as a result of smoking cessation).

The HBM also holds that behavior change, especially one associated with personal health, more likely occurs when a person, or a group of persons, are convinced that their respective behavior makes them more vulnerable to a disease(s), than others whose behavior is at variance with theirs, and that behavior, if pursued, can lead to severe, undesirable consequences, such as heart disease or cancer (Glanz et al., 1997). The TRA postulates that a person's behavioral intention, a joint function of the person's attitude toward the behavior and his/her subjective norms about the behavior, is the immediate and most important determinants of behavior (Glanz et al., 1997). In the Youth-PASS program, we seek to change the participating youths' attitudes towards smoking by altering their belief about consequences of tobacco use, thus changing their behavioral intention, which ultimately leads to a change in their behavior.

METHODS

The purpose of this study is to evaluate the effectiveness of a research-based comprehensive culturally tailored tobacco Youth-PASS prevention/intervention program targeting Asian American youth. Specifically, the research was designed to assess: 1) the efficacy of the Youth-PASS in changing knowledge, attitudes and behavioral intention toward tobacco use among program participants; 2) participants' satisfaction with the program content, method and style; and 3) improvement of Youth-PASS through participant contributions. A long-term goal was to assess participants' willingness and commitment to carry the tobacco message back to the Asian community, with a parallel aim of improving the health of the most vulnerable among them--infants and children living with adult smokers in their immediate environment.

Participants

The study sample included Asian American male and female youth, smokers and nonsmokers, who were residents of the Delaware Valley Region of PA and NJ. The sample included 161 participants distributed as follows: males (n = 82); females (n = 75). The average age of the sample was 14.1 years (SD = 2.1 years), and ranged from 10 to 22 years. The ethnic distribution consisted of Chinese (N = 67, 41.6%); Korean (N = 23, 14.3%); Vietnamese (N = 28, 17.4%); Cambodian (N = 20, 12.4%); and Other (N = 23, 14.3%). Of the participants, 83.9% (n = 135) were nonsmokers; 5.6% (n = 9) were current smokers; and 10.5% (n = 17) were ex-smokers.

Evaluation Design and Measures

Participants were recruited from schools with large enrollments of Asian students and from an Asian community-based after-school program. Oral and written explanation of the purpose of the study was provided to participants. Participants were informed that they might choose whether or not to complete the survey form without any consequences. The evaluation study used a one-group pretest-posttest design by comparing the same group(s) at two points in time, before and after the intervention program. Self-administrated written pretests were completed by participants and collected prior to the prevention workshop; posttest questionnaires were collected immediately following the program. Average time for completion of the pretest and posttest questionnaires was 5-10 minutes. Two evaluation questionnaires were developed, field tested and modified for the study. They were designed to elicit demographic data (age, gender, and smoking status, among others), knowledge about and attitudes toward tobacco and tobacco use, and behavior intentions and satisfaction. Questions or statements regarding participants' "attitude" were designed to elicit information that is associated with health behavior change. They include questions that measured participants' attitudes toward the adverse effects of smoking (e.g. bad breath or yellow teeth), while others measured behavior intention or participants' willingness or intent to share information and experiences acquired during training with family members and friends; and still others that measured satisfaction with the prevention program and the style of program presentation. A process evaluation was also conducted; its purpose was to document observations that would lead to program improvement.

All participants completed written pre- and post-test questionnaires prior to and following the prevention program. The tests were identical with one exception: "demographics" was excluded from the post-test. All subjects received oral and written explanation of the purpose of the study, and standard survey methodology was followed to assure data integrity and compliance with IRB requirements. All participants completed the prevention program.

Data Analysis

Descriptive statistics, rates and constituent proportions were used to depict the status and changes of study variables--knowledge, attitudes, behavior intention and satisfaction. A total score of 17 was used as an index of the overall level of knowledge, represented by values ranging from 0-17, or lowest to highest score on the surveyed knowledge questionnaire items. Similarly, a score of 24 on the attitude variable signified the highest possible score achievable. Attitude was assessed by six different questions, each of which was represented by values ranging from 1 (lowest), to 4 (highest), and a total score ranging from 4 (lowest) to 24 (highest), the latter being the expected attitude. The behavior intention score, the subject's intention to share information acquired from the prevention program with family and friends, was represented by values ranging from 1 to 4, or lowest to highest, respectively. Scores defined above were used in analyzing correlations and comparing mean differences among various groups, such as gender, age, and smoking status (smoker, nonsmoker). The McNemar statistical test was used to test the mean difference between pretest and posttest. A one-way analysis of variance was used to compare the difference in change among subgroups. The Pearson correlation was used to analyze the relationship between knowledge and behavior intention, and between attitude and behavior intention.

RESULTS

Knowledge change

There was a significant positive mean increase of 4.1 points (from 9.0 to 13.1) from pre- to post-test among ethnic subgroups (Table 1). The variability in pretest awareness rates of tobacco-related knowledge ranged from 8.7% of participants who were aware that parents' smoking can lead to early ear infection in children, to 93.2% who were aware of the relationship between smoking and cancer (Table 2). Participants were also aware of the relationship between smoking and bad breath (92.5%), and smoking and yellow teeth (91.9%). While post-test awareness rates showed increases across all questions, the most significant rate increases were on questions that related to annual tobacco outlays on advertising (45.4%), the relationship between tobacco use and cervical cancer (42.2%), and the similarities between chemicals in tobacco and insecticides (41.0%).

Attitude change

Overall, there was a small (0.60) but significant change between the pre- and post-test mean attitude score from 19.9 to 20.5 (p = 0.007) (Table 1). Other significant increases (p < 0.05) were also reflected in subgroup attitude scores between males (1.0) and youth older than 14 years (0.60), and between males (1.0) and females (0.2).

Table 3 shows results of responses to positive attitudes and negative attitudes. There was a change in the appropriate direction for all positive and negative attitude items. There was significant change (p < .05) in "smoke from others' cigarettes will harm me" (11.2%).

Posttest behavior intention

The large majority of participants (90.7%) indicated intention to share information and experiences acquired during the prevention program with family members and friends.

Knowledge, attitude and behavior intention for smokers and nonsmokers

There was a significant increase in mean knowledge score at post intervention for smokers (3.7) and nonsmokers (4.2) (Table 4). Both groups were equal (9.0) in pretest knowledge scores, indicating similar knowledge change for smokers and nonsmokers. The posttest mean attitude score had a small but significant difference for nonsmokers (p = 0.031), but not for smokers (p = 0.095). On average, nonsmokers showed significantly higher attitude scores than smokers in both pretest and posttest. The mean score of behavior intention for nonsmokers (3.3) was significantly higher than for smokers (2.8).

Correlation of behavior intention with changes of knowledge and attitudes

Behavior intention was more closely associated with attitude change than with knowledge change (Table 5). There was a significant correlation (r = 0.31) between change of attitude and behavior intention. In addition, there were significant correlations between behavior intention and changes in attitude for males (r = 0.38) and females (r = 0.26), youth younger than 14 years (r = 0.47), and nonsmokers (r = 0.33).

Satisfaction with the prevention program

About 70% of participants responded favorably to prevention program content and training delivery style. One third of participants rates program content "excellent" (36%) or "good" (32.3%), over 24% rated it "fair" and about 6%, "poor" (Figure 1). Similarly, style of delivery received the following high levels of satisfaction: 37.2% "excellent"; 51.3% "good"; 8.3% "fair", and 3.2% "poor" (Figure 2).

Suggestions for improving the prevention program

Participants contributed a range of comments regarding improvement of the Youth-PASS smoking prevention program. Improvement in the program consisted of more effective knowledge delivery, such as increased numbers of activities, additional visual presentations, models and videos, as well as modifications to the timetable.

DISCUSSION

The Youth-PASS is a community-based and culturally-tailored prevention program designed to fill a tobacco prevention gap, a supplement to other school-based prevention programs, particularly in school systems with a large enrollment of Asian Americans. Youth-PASS uses tested strategies to counter the influence of tobacco advertising and to inculcate in youth a different perspective about tobacco. The Youth-PASS program attempts to counter the advertising of the tobacco industry, which seeks to capitalize on the limited knowledge about the deleterious effects of tobacco on health. The tobacco industry spends in excess of three billion dollars annually on advertising to keep smokers addicted and to recruit new smokers to replace those who do quit or die from smoking-related illnesses (Federal Trade Commission, 1999; Plymale, 1992). The ultimate goal of Youth-PASS is to avert catastrophic tobacco-related health problems in later life. In more practical terms, Youth-PASS increases awareness about tobacco's direct effects on health, and motivates and assists youth in cultivating and pursuing healthy behaviors achieved either through abstinence from tobacco or through cessation.

The findings of this study suggest that the Youth-PASS training program is an effective tool to increase tobacco knowledge among Asian American youth, in general, with few exceptions, pretest-posttest mean scores showed significant improvement in knowledge about tobacco and its deleterious effects on health. More than 90% of participants in the study were able to recognize the cause-effect relationship between tobacco use and respiratory illnesses and cancer. A large majority intended to carry the information to family and friends upon completion of the training program, which can help expand the impact of the program.

Pre- and post-test scores also indicated a small but significant change in attitude toward tobacco and smoking. This change was not as pronounced as that of knowledge change. Earlier studies have shown that attitudinal shifts are less pronounced because attitudes are more difficult to change than knowledge (Clarke & Aish, 2002). Cuijpers and colleagues (2002) observed a similar phenomenon regarding drug use where there was increase in knowledge but not a change in attitudes toward drugs. Behavior theorists assert a close relationship between knowledge, attitudes and behavior (Glanz et al., 1997). This study revealed a significant correlation between behavior intention and attitudes, but not between behavior intention and knowledge. This finding corroborated earlier studies that concluded that behaviors are determined more by attitudes than knowledge (Tipton, 1988; Torabi, Yang, & Li, 2002). In our study, the correlation coefficient between behavior intention and attitude, although low, was significant (r = 0.31). This correlation, however, varied among subgroups; for example, it was higher among males than among females. These results led us to the conclusion that relationships between intention behaviors, attitudes and knowledge are complex and are not amenable to facile description.

Limitations

We are aware of a number of study limitations. First, the survey consisted of self-reports and thus relies on the veracity of the participants. Second, the design of this initial study was a one-group pre- and post-test design that limits a comparative analysis with a control group that did not receive the intervention. As a result, it is difficult to know the effects that other factors may have had on the participants, independent of the intervention. And third, the relatively small sample size precluded meaningful comparisons of the differences in knowledge, attitude and behavior intention among smokers and nonsmokers. Notwithstanding these limitations, the findings that the differences between smokers and nonsmokers were in attitude and behavior intention, and that nonsmokers had more positive and healthy attitudes and behavior intention than smokers were significant enough to encourage further research.

Numerous surveys have indicated that adolescent smokers are well aware of the health consequences of smoking. Researchers note that it is quite unlikely that simple lack of knowledge is the under lying reason that prevents people from avoiding harmful behavior (Hansen, 1992). According to CDC recommendations, an effective smoking prevention program for youth should be more comprehensive and should include provision of information on the social influences of and peer norms regarding tobacco use, training for teachers, and development and enforcement of tobacco free policies in schools (CDC, 1994b; Lantz et al., 2000). These strategies will be incorporated into the Youth-PASS program.

Recommendations for Future Research

Given the positive findings in this initial study, future research could utilize a quasi-experimental design with control and intervention groups so that comparison can be made at post-test. In addition, the curriculum can be applied to a larger sample size, so that comparisons can be made between smokers and nonsmokers, and between Asian ethnic subgroups. A repeated measures analysis could be conducted, a follow-up which measures behavior intention and attitude change at time periods beyond completion of the program, such as at 3-month or 6-month intervals. School-based smoking-prevention programs, based on a model of identifying social influences on smoking and providing skills to resist those influences, have been used successfully in many states. While these programs have demonstrated substantial reductions in adolescent smoking prevalence, their implementation outside the context of community-based activities may reduce their long-term effectiveness and sustainability (CDC, 1994b; Peterson et al., 2000; U.S. DHHD, 2000). Community-based culturally tailored interventions should be further studied to determine the role they can play in further contributing to gains achieved in school-based programs.

The vast majority of participants was satisfied with the Youth-PASS program content and style of delivery, an indication that the program was not only culturally appropriate and delivered in a manner acceptable to the target group, but also that the objectives of the program were met with minimal resistance. Participants' contributions toward improvement of the effectiveness of the program underscored further participant satisfaction with the program.

In the U.S. smoking is no longer a culturally acceptable behavior. The tobacco industry thrives on young smokers who are vulnerable to nicotine dependency and to tobacco-associated poor health and early death (CDC, 1994a). Asian youth represent a new generation of smokers and therefore there is an urgent need to expand the national effort to prevent Asian Americans from initiating a behavior that compromises their health and well-being.

Table 1
Scores of Knowledge, Attitude and Behavior Intention
by Gender and Age (Mean [+ or -] SD)

Gender &                    Pretest             Posttest
Age Group                    Score                Score

Knowledge Score

  Total                9.0 [+ or -] 3.2     13.1 [+ or -] 3.8
  Gender
    Male               9.2 [+ or -] 3.1     13.1 [+ or -] 4.2
    Female             8.9 [+ or -] 3.2     13.2 [+ or -] 3.3
  Age Group
    < 14               8.9 [+ or -] 3.4     12.6 [+ or -] 4.0
    [greater than or
      equal to] 14     9.4 [+ or -] 3.1    13.8 [+ or -] 33.5

Attitude Score

  Total                19.9 [+ or -] 2.8    20.5 [+ or -] 3.2
  Gender
    Male               19.6 [+ or -] 2.9    20.6 [+ or -] 3.2
    Female            20.1 [+ or -] 2.73    20.3 [+ or -] 3.2
  Age Group
    < 14               19.9 [+ or -] 2.8    20.4 [+ or -] 3.4
    [greater than or
      equal to] 14     19.9 [+ or -] 2.8    20.5 [+ or -] 2.8

Behavior Intention Score

  Total                                     3.2 [+ or -] 0.8
  Gender
    Male                                    3.2 [+ or -] 0.8
    Female                                  3.3 [+ or -] 0.7
  Age Group
    < 14                                    3.3 [+ or -] 0.7
    [greater than or
      equal to] 14                          3.2 [+ or -] 0.8

                                          P Value
Gender &                                 (a) (Pre-   P Value *
Age Group                Difference     & Post-Test  (Groups)

Knowledge Score

  Total               4.1 [+ or -] 4.0     0.001
  Gender                                               0.555
    Male              3.9 [+ or -] 4.5     0.001
    Female            4.3 [+ or -] 3.3     0.001
  Age Group                                            0.380
    < 14              3.8 [+ or -] 4.4     0.001
    [greater than or
      equal to] 14    4.4 [+ or -] 4.0     0.001

Attitude Score

  Total               0.6 [+ or -] 2.6     0.007
  Gender                                               0.046
    Male              1.0 [+ or -] 2.8     0.002
    Female            0.2 [+ or -] 2.3     0.601
  Age Group                                            0.892
    < 14              0.5 [+ or -] 2.7     0.095
    [greater than or
      equal to] 14    0.6 [+ or -] 2.6     0.038

Behavior Intention Score

  Total
  Gender                                               0.463
    Male
    Female
  Age Group                                            0.300
    < 14
    [greater than or
      equal to] 14

(a) Paired t-test

* One way analysis of variance

Table 2
Knowledge Awareness Change on Tobacco-Related Factors
Affecting Health of Smokers and Nonsmokers
Exposed to Secondhand Smoke (n = 161)

                                               Awareness Rate (%)

Knowledge Items                           Pretest  Posttest  Increase

Chemicals in Tobacco
  Floor Cleaner                            31.7      71.4     39.7 *
  Insect Poison                            27.3      68.3     41.0 *
  Car Exhaust Fumes                        32.9      70.2     37.3 *

Tobacco-Related Diseases/Conditions
  Lung Cancer                              93.2      96.9      3.7
  Mouth Cancer                             60.2      85.1     24.9 *
  Cervical Cancer                          37.9      80.1     42.2 *
  Heart Disease                            76.4      89.4     13.0 *
  Bad Breath                               92.5      93.8      1.3
  Wrinkles                                 50.9      83.9     33.0 *
  Yellow Teeth                             91.9      95.0      3.1

Children Affected by Parents' Smoking
  Trend to Smoke                           68.3      72.7      4.4
  Easy to Get Ear Infections                8.7      42.2     33.5 *
  Easy to Get Lung Diseases                67.1      79.5     12.4 *

Other Knowledge about Tobacco Production
  Nicotine Addiction                       51.6      62.1     10.5 *
  Annual Advertising Outlay of Tobacco
    Companies                              36.0      81.4     45.4 *
  Beginning Age of Youth Smoker            46.0      82.0     36.0 *
  Population of Youth Smoker               29.8      58.4     28.6 *

* P < 0.05, McNemar test

Table 3
Pretest and Posttest Scores for
Change of Attitude toward Tobacco among Youth

                                               Rate of Agreement (%)
                                                     (n = 161)

Attitude Items                              Pretest  Posttest  Increase

Positive Attitudes
  Encourage Smoker's Friends or Family to
    Quit                                     48.4      55.9      7.5
  Refuse to Smoke even if Best Friends
    Offered                                  52.2      59.0      6.8
  Smoke from Others' Cigarettes Will
    Harm Me                                  46.6      57.8     11.2 *

Negative Attitudes
  Don't Believe Tobacco Causes Bad Breath
    and Yellow Teeth                         14.9      13.0     -1.9
  Smoking Would Improve One's Social Life     5.0      6.2       1.2
  Smoking Is Cool                             4.3      5.0       0.7

* P < 0.05, McNemar test

Table 4
Scores of Knowledge, Attitude and Behavior Intention
by Smoking Status (Mean [+ or -] SD)

                          Pretest            Posttest
Smoking Status             Score              Score

Knowledge Score
  Nonsmoker           9.0 [+ or -] 3.2  13.2 [+ or -] 3.8
  Smoker              9.0 [+ or -] 3.0  12.7 [+ or -] 3.9
  P-Value * (Groups)       0.912              0.491

Attitude Score
  Nonsmoker           20.2 [+ or -] 3.2 20.7 [+ or -] 3.2
  Smoker              17.5 [+ or -] 3.0 18.6 [+ or -] 2.7
  P-Value * (Groups)       0.001              0.005

Behavior Intention         Score
  Nonsmoker                              3.3 [+ or -] 0.8
  Smoker                                 2.8 [+ or -] 0.9
  P-Value * (Groups)                          0.005

                                           P-Value (a)
Smoking Status           Difference     (Pre- & Post Test)

Knowledge Score
  Nonsmoker           4.2 [+ or -] 4.0        0.001
  Smoker              3.7 [+ or -] 4.0        0.001
  P-Value * (Groups)       0.569

Attitude Score
  Nonsmoker           0.5 [+ or -] 2.5        0.031
  Smoker              1.1 [+ or -] 3.2        0.095
  P-Value * (Groups)       0.279

Behavior Intention
  Nonsmoker
  Smoker
  P-Value * (Groups)

(a) Paired t-test

* One way analysis of variance

Table 5
Correlation between Changes of
Knowledge, Attitudes and Behaviors

                    Behavior Intention   Behavior Intention
                       and Changes          and Changes
Group                  in Knowledge         in Attitudes

Gender                      r                    r
  Male                    -0.02                0.38 *
  Female                   0.14                0.26 *
Age Group
  < 14                     0.04                0.47 *
  [greater than
  or equal to] 14          0.07                0.18
Smoking Status
  Nonsmoker                0.03                0.33 *
  Smoker                   0.03                0.39
Total                      0.04                0.31 *

* Significant p < 0.05

Figure 1
Participant satisfaction with program content

Poor         6.3
Fair        24.8
Good        32.3
Excellent   36.6

Note: Table made from bar graph.

Figure 2
Participant satisfaction with program delivery style

Poor         3.2
Fair         8.3
Good        51.3
Excellent   37.2

Note: Table made from bar graph.

References

The American Osteopathic Association. (2002). Smoking: An Increasing Problem Among America's Youth. Retrieved September 10,2002, from http://www.aoa-net.org/Consumers/smoking.htm.

Centers for Disease Control and Prevention. (1992). Tobacco, Alcohol, and Other Drug Use Among High School Students--United States, 1991. Morbidity and Mortality Weekly Report, 41(37), 698-703.

Centers for Disease Control and Prevention. (1994a). Preventing Tobacco Use Among Young People: A Report of the Surgeon General (Executive Summary). Morbidity and Mortality Weekly Report, 43(RR-4), 1-10.

Centers for Disease Control and Prevention. (1994b). Guidelines for school health programs to prevent tobacco use and addiction. Morbidity and Mortality, Weekly Report, 43(RR-2).

Centers for Disease Control and Prevention. (1999). Cigarette smoking among adults--United States, 1997. Morbidity and Mortaliy Weekly Report, 48, 993-996.

Centers for Disease Control and Prevention. (2000a). Cigarette smoking among adults--United States, 1998. Morbidity and Mortality; Weekly Report, 49(39), 881-884.

Centers for Disease Control and Prevention. (2000b). Global Tobacco Prevention and Control. Retrieved October 11, 2002, from http:// www.cdc.gov/tobacco/global/gyts/factsheets/US_factsheet.htm

Centers for Disease Control and Prevention. (2000c) Youth Risk Behavior Surveillance--United States, 1999. Morbidity and Mortality Weekly Report, 49(SS05), 1-96.

Chen, M.S. & Hawks, B.L. (1995). A debunking of the myth of the healthy Asian American and Pacific Islander. American Journal of Health Promotion, 9, 261-268.

Clarke, K.E. & Aish, A. (2002). An exploration of health beliefs and attitudes of smokers with vascular disease who participate in or decline a smoking cessation program. Journal of Vascular Nursing, 20(3), 96-105.

Cuijpers, P., Jonkers, R., de W.I., & de J.A. (2002). The effects of drug abuse prevention at school: The "Healthy School and Drugs" project. Addiction, 97(1), 67-73.

Elders, M., Perry, C., Eriksen, M., & Giovino, G. (1994). The report of the Surgeon General: Preventing tobacco use among young people. American Journal of Public Health, 84(4), 543-547.

Federal Trade Commission. (1999). Pursuant to the Federal Cigarette Labeling and Advertising Act. Report to Congress For 1997, pp. 15-23.

Glanz, K., Lewis, F.M., & Rimer, B.K. (1997). Health behavior and health education (2nd ed.). San Francisco: Jossey-Bass Inc.

Hansen, W. (1992). School-based substance abuse prevention: A review of the state of the art in curriculum, 1980-1990. Health Education Research, 7(3), 403-430.

Lantz, P.M., Jacobson, P.D., Warner, K.E., Wasserman, J., Pollack, H.A., Berson, J., & Ahlstrom, A. (2000). Investing in youth tobacco control: A review of smoking prevention and control strategies. Tobacco Control, 9, 47-63.

Little, H. (2000). Behavioral Mechanisms Underlying the Link Between Smoking and Drinking. Alcohol Research & Health, 24(4), 215-223.

Ma, G.X., Tan, Y., Su, X.F., Toubbeh, J.I., & Lan, Y.J. (in press, 2004). Acculturation and smoking behaviors among Asian American Smokers. Health Promotion Practice.

Mermelstein, R. (1999). Explanations of ethnic and gender differences in youth smoking: A multi-site, qualitative investigation. Nicotine and Tobacco Research, 1, S91-S98.

Peterson, A. V.J., Kealey, K.A., Mann, S.L., Marek, P.M., & Sarason, I.G. (2000). Hutchinson Smoking Prevention Project: Long-term randomized trial in school-based tobacco use prevention--results on smoking. Journal of the National Cancer Institute, 92(24), 1979-1991.

Pierce, J.P. & Gilpin, E. (1996). How long will today's new adolescent smoker be addicted to cigarettes? American Journal of Public Health, 86(2), 253-256.

Plymale, R.D. (1992). Tobacco Risk Awareness. Journal of Extension, 30(2).

Substance Abuse and Mental Health Services Administration. (1998). Preliminary results from the 1997 National Household Survey on Drug Abuse (DHHS Publication No. SMA 98-3251), Washington, DC: U.S. Government Printing Office.

Tipton, R.M. (1988). The effects of beliefs about smoking and health on smoking cessation. Journal of Psychology, 122(4), 313-321.

Torabi, M.R., Yang, J., & Li, J. (2002). Comparison of tobacco use knowledge, attitude and practice among college students in China and the United States. Health Promotion International, 17(3), 247-253.

U.S. Department of Commerce, Bureau of the Census, Economic and Statistics Administration. (1999). We the Americans: Asians. Retrieved January 12, 2002, from http://www.census.gov/apsd/ www/wepeople.html.

U.S. Department of Health and Human Services. (2000). Reducing Tobacco Use: A Report of the Surgeon General. Centers for Disease Control and Prevention.

U.S. Department of Health and Human Services. (1998). Tobacco use among U.S. racial/ethnic minority groups--African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: A report of the surgeon general. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health.

U.S. Census Bureau. (2000a). Asian and Pacific Islander Populations. Retrieved December 20, 2002, from http://www.census.gov/ population/www/socdemo/race/api.html.

U.S. Census Bureau. (2000b). Census 2000 Summary File 1 (SF 1) 100-Percent Data. Retrieved December 20, 2002, from http:// factfinder.census.gov/servlet/BasicFactsServlet?_basicfacts.

Wiecha, J.M. (1996). Differences in patterns of tobacco use in Vietnamese, African-American, Hispanic, and Caucasian adolescents in Worcester, Massachusetts. American Journal of Preventive Medicine, 12(1), 29-37.

Grace X. Ma, Tertile University

Yajia Lan, Temple University and Sichuan University 

Rosita L. Edwards, Temple University

Steven E. Shive, Temple University and East Stroudsburg University

Tolan Chau, Albert Einstein Medical Center

Author Note

Grace X. Ma, Department of Public Health, Center for Asian Health, College of Health Professions, Temple University; Yajia Lan, Center for Asian Health, Department of Public Health, Temple University; also affiliated with the School of Public Health, Sichuan University, China; Rosita L. Edwards, Center for Asian Health, Department of Public Health, Temple University; Steven E. Shire, Center for Asian Health, Temple University; also affiliated with the Department of Health, East Stroudsburg University; Tolan Chau, A Better Start Women and Children's Services, Albert Einstein Medical Center.

Correspondence concerning this article should be addressed to Grace X. Ma, Department of Public Health, Center for Asian Health, College of Health Professions, Temple University, 304A Vivacqua Hall, P.O. Box 2843, Philadelphia, Pennsylvania 19122-0843. E-mail: [e-mail].