The first puff: Forces in smoking initiation amongCalifornians of Korean descent

C. Richard Hofstetter, Melbourne F. Hovell, Kyoung-Rae Jung, Rema Raman,Veronica Irvin, Richard Ni

Received 12 July 2006; accepted 14 February 2007

This study presents the correlates of initial exposure to cigarettes, variables associated with smoking prevalenceand with continued smoking (or not) among adult Californians of Korean descent who have any initial exposure tocigarettes. Among those who have taken a puff, social contingencies contrast those who become current smokersfrom those who do not. Data were drawn from telephone interviews with adults (N52,830) developed from arandom sampling of listed persons in California with Korean surnames during 2000–2001. Of the attemptedinterviews, 86% were completed; and 85% of the interviews were conducted in Korean. Nearly half of allrespondents (49.0%) had been exposed to cigarettes, and 41.9% of these reported current smoking, according toCenters for Disease Control and Prevention criteria (currently smoke and have smoked 100 cigarettes duringlifetime). Multivariate analysis suggests that social contingencies may influence both initial exposure to tobaccoand continued smoking among Californians of Korean descent. Influences of acculturation on taking the first puffand on current smoking status diverged by gender. Social support increased the likelihood of the first puff amongboth genders, but the association was stronger among females than among males. Social reinforcers that lead totaking the first puff also discriminated between those who became current smokers and those who did not.Interventions should be directed at these variables among young Korean nonsmokers and new smokers.

Introduction

Persons of Korean descent constitute a small but

rapidly growing minority in the United States (Asian/

Pacific Islander Data Consortium, 2002; Yu, Choe,

& Han, 2000). Male Koreans are characterized by

relatively high rates of smoking, and female Koreans

are characterized by relatively low rates compared

with other Americans (Carr, Beers, Kassebaum, &

Chen, 2005; Centers for Disease Control and

Prevention [CDC], 1997, 2001, 2002; Korean

Statistical Information System, 2006; Lee, Sobal, &

Frongillo, 2000; Mackay, Jemal, Lee, & Parkin,

2006; Mermelstein, 1999; U.S. Department of Health

and Human Services [USDHHS], 1998), but accul-

turation is related negatively to smoking cigarettes

among Korean males and positively to smoking

cigarettes among Korean females in California

(Hofstetter et al., 2004). Surveys conducted in the

language preferred by respondents (predominantly

Korean among adults) also documented higher rates

of smoking among Korean males than did surveys of

Koreans in the United States conducted only in

English, no doubt because of differences in accul-

turation (CDC, 1997; K. Kim et al., 2000; National

Asian Women’s Health Organization, 1998;

USDHHS, n.d.).

Smoking prevalence in a 1994–1995 Alameda

County, California, survey conducted in Korean

and English was 39% for Korean males and 6% for

Korean females (CDC, 1997). Using the data from

this study, Hofstetter and coworkers (2004) reported

ISSN 1462-2203 print/ISSN 1469-994X online # 2007 Society for Research on Nicotine and Tobacco

DOI: 10.1080/14622200701704863

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C. Richard Hofstetter, Ph.D., Graduate School of Public Health, San

Diego State University; Melbourne F. Hovell, M.P.H., Ph.D.,

Graduate School of Public Health, and Center for Behavioral

Epidemiology and Community Health, San Diego State University,

San Diego, CA; Veronica Irvin, M.P.H., Richard Ni, M.A., Center for

Behavioral Epidemiology and Community Health, San Diego State

University, San Diego, CA; Kyoung-Rae Jung, Department of

Psychology, University of Minnesota, Minneapolis, MN; Rema

Raman, Ph.D., Department of Family and Preventive Medicine,

University of California, San Diego, La Jolla, CA.

Correspondence: C. Richard Hofstetter, Ph.D., Center for

Behavioral Epidemiology and Community Health, Graduate School

of Public Health, San Diego State University, 9245 Sky Park Court,

Suite 230, San Diego, CA 92123, USA. Tel: +1 (858) 505-4770 x 146;

Fax: +1 (858) 505-8614; E-mail: rhofstet@mail.sdsu.edu

Nicotine & Tobacco Research Volume 9, Number 12 (Month 2007) 1–10

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CDC smoking prevalence (ever smoked 100 cigar-

ettes and currently smokers) of 31.2% for men and

3.7% for women among all Californians of Korean

descent. These rates compare to 25.5% current

prevalence among all American men and 21.5%

current prevalence among all American women

(CDC, 2003). Data for all adults in California in

2001 showed that 13.0% of California adults (15.4%

of males and 10.8% of females) were current smokers

(Gilpin et al., 2001). Several studies also have linked

smoking and other health risk behaviors to accul-

turation (K. Kim et al., 2000; Lee et al., 2000; Lew et

al., 2001).

Our previous empirical findings and the behavioral

ecological model were used as the basis for the

present study’s analysis plan. The behavioral ecolo-

gical model casts behavior as a function of physio-

logical, physical, and social contingencies of

reinforcement, and both summative and synergistic

interactions within and across levels of society

(Hovell, Wahlgren, & Gehrman, 2002). The model

assumes that the power of contingencies—such as the

nearly immediate effect of nicotine on the brain, and

local social reinforcement from friends who may

offer cigarettes, or social company in the context of

tobacco use—provide the most immediate and

therefore powerful contingencies of reinforcement.

These contingencies may be especially true among

Korean males when smoking initiation is attributed

to peer pressure in schools and military and smoking

maintenance is attributed to social interactions

during business dealings (S. S. Kim, Son, & Nam,

2005). Further, the model emphasizes the potential

role of contingencies at relatively ‘‘high’’ levels of

society, such as media and law, as moderators or

motivating operations that alter the effect of

contingencies that may be derived from microsocial

networks, such as family and close friends (Martin &

Pear, 2007). For Korean male immigrants to the

United States, smoking might be used to maintain

their identity as Korean males or it might be reduced

as they assimilate to California tobacco stigmas.

However, these contingencies interact in as-yet

uncertain ways with as-yet unknown numbers of

cultural contingencies extending throughout the

society.

The present study explored the possible correlates

of adult respondents’ report of having ever taken one

puff of a cigarette and, among the group of puffers,

the correlates of those who became regular smokers.

This study was based in part on our previous cross-

sectional analyses of tobacco use that showed an

interaction between gender and acculturation

(Hofstetter et al., 2004). Thus this analysis was

designed to explore the possibility of a similar

interaction for respondents who reported ever having

taken a puff on a cigarette. This study also explored

the degree to which the correlates for taking the first

puff differed from those for subsequent established

smoking.

Method

Sample

Sampling was designed to represent adult Califor-

nians of Korean descent. Study procedures were

approved by the institutional review board at San

Diego State University.

Telephone interviews were conducted with a

sample of adults (aged 18 years or older) of Korean

descent who resided in households that had residen-

tial telephones in California during 2000–2001. An

electronic list of all residential telephones listed in

California was purchased from a commercial firm,

and all non-Korean surnames were purged from the

list. Persons whose first names were Asian but not

Korean were then purged from the list. This

approach eliminated most people with surnames

common to Korea and other nations (e.g., Ho,

Cho, who may be of Chinese descent). Persons with

Korean surnames and Anglicized first names were

retained in the sample, and the list was then sorted

into random order for interviewing. All potential

respondents were then filtered to ensure that they

were of Korean descent during the introduction to

the survey. Stratified by gender, respondents of

Korean descent were then selected randomly in each

household by using the most recent birthday

procedure (Frey, 1989).

Figure 1 depicts the disposition of the sample.

From this listing of telephone numbers, 22,252

persons were called—2,830 completed the survey,

466 refused, 10,061 were ineligible to participate, and

8,895 were not surveyed for other reasons. Ineligible

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Figure 1. Tree diagram of disposition of sample.Ineligible includes non-Koreans, business numbers, andpersons who speak neither English nor Korean. Otherincludes disconnected numbers, machines, no answerafter seven attempts, and line busy through sevenattempts.

2 THE FIRST PUFF

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participants included non-Koreans, business num-

bers, and persons who spoke neither Korean nor

English. Others included disconnected numbers,

answering machines, no answers, and lines busy.

Up to eight follow-up attempts were made to contact

potential respondents. Of the 3,296 eligible respon-dents contacted by telephone, 86% agreed to

participate in the survey.

Language

The survey instrument was constructed initially in

English and translated into Korean by bilingual

coinvestigators. Precise wording was formulated

based on feedback from two focus groups ofKorean Americans living in the San Diego area.

The instrument was backtranslated, modified, and

retranslated several times with the aid of study

coinvestigators who are faculty members at Myongji

and Seoul National Universities in Korea. All

interviewers and their supervisor were bilingual in

English and Korean. Since a high proportion of

Koreans in the United States have immigratedrecently, initial contact was made in the Korean

language and interviewers were instructed to shift to

English if that was the respondent’s preference. Up

to seven callbacks were used, and a specially trained,

skilled interviewer attempted to convert refusals.

Approximately 86% of all eligible respondents

completed interviews.

The sampling procedure resulted in minor over-representation of older persons and under-represen-

tation of younger persons compared with the most

recent U.S. Census data available for the Korean

population in California (Yu et al., 2002). Data were

weighted to the most recent age by gender adult

census distribution, although no significant differ-

ences appeared in conclusions from analyses using

either weighted or unweighted data.

Measures

Having taken a puff. Persons who answered yes to

the question ‘‘Have you ever tried any kind of

tobacco, even a few puffs?’’ were coded as puffers.

CDC smoking. Smoking was measured by responses

to the following questions: (a) ‘‘Have you smoked

100 cigarettes during your lifetime?’’ and (b) ‘‘Do

you now smoke cigarettes every day, some days, ornot at all?’’ (USDHHS, 1996). Current smokers were

those who smoked 100 cigarettes and said they

smoked cigarettes every day or some days.

Acculturation to U.S. society. The acculturation scale

used in the present study was adapted from the

Suinn–Lew Asian self-identity acculturation to U.S.

society scale (Suinn, Khoo, & Ahuna, 1995; Suinn,

Rickard-Figueroa, Lew, & Vigil, 1987). Because the

original scale was designed for paper and pencil

administration, some items were reformatted for

telephone administration. Items were designed to

measure aspects of cultural preferences involving

language, music, food, and self-identification includ-

ing how the self is identified with the U.S. and Korea,

father’s identification, and social linkages including

ethnicity of peers and preferred associations.

Reported proportions of education and years of

living in the United States were added to the original

scale for this analysis. These items were highly

correlated with other indicators used in the original

scale.

After conversion to a common metric (z-scores),

items were subjected to a principal components

analysis. Although two components emerged from

the analysis using the customary eigenvalue of 1.0 as

a cut-off, a single general dimension explained 83.1%

of the common and 47.3% of the total variance

among items. Exact wording of items, item loadings,

communalities, and proportion of total variance

explained are available in a methodological appendix

available from the senior author. For purposes of

analysis, a general acculturation to U.S. society scale

was formed by computing the mean of standardized

items (M52.04, SD58.62, Cronbach’s a5.90) after

permitting up to two scores to be missing, in order to

minimize loss of respondents. Analyses demonstrated

that the missing data treatment made no significant

difference in findings.

Work status. Whether or not respondents worked

outside the home was measured as a dummy

variable. Reported working outside the home was

coded as ‘‘1,’’ and not working outside the home was

coded as ‘‘0.’’

Social support for smoking. A social support for

nonsmoking scale (discouragement of smoking) was

formed by counting the number of persons (spouse,

parents, siblings, friends, children, grandparents,

aunts, uncles, teachers, and other persons) who

‘‘discourage you from smoking.’’ Responses were

coded 0 to 9 (M55.69, SD53.01, Cronbach’s

a5.97). A high score indicated high discouragement

from smoking.

Models for smoking. A scale of models for smoking

was computed by counting the number of persons

(spouse, parents, siblings, friends, children, grand-

parents, aunts, uncles, teachers, children’s friends,

and other persons) who respondents reported ‘‘reg-

ularly smok(ing) cigarettes.’’ Responses ranged from

0 to 6 (M52.68, SD51.72, Cronbach’s a5.73).

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NICOTINE & TOBACCO RESEARCH 3

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Demographic variables. Education was measured in

years completed both in Korea and in the United

States. Given that some grades were commonly

repeated after immigration, a composite measure

was formed so that no common year was counted

twice. Age was measured in years, and gender was

determined by interviewers (who asked explicitly if

gender of the respondent was unclear).

Results

Sample

Table 1 reports demographic characteristics of the

study sample. Mean age of respondents, measured as

a continuous variable, was 40.0 years (SD515.0);

93.7% said that they were born in Korea; and 98.5%

reported that their parents were born in Korea.

Respondents reported living longer in Korea

(M523.8 years, SD514.2) than in the United

States (M515.5 years, SD58.7). Mean years of

education also were higher in Korea (10.4 years,

SD56.0) than in the United States (6.5 years,

SD57.4). About 44.7% of respondents were male;

67.4% worked outside the home; 30.9% were single,

63.0% married, 4.5% widowed, 1.4% divorced, and

0.3% cohabiting; and 99.1% of the married persons

reporting being married to a person of Korean

nationality. Most respondents (96.0%) were rated as

cooperative or very cooperative by interviewers, and

96.6% were rated as having a high or very high level

of understanding of the interview questions.

Prevalence of taking a puff

About 49.0% of Californians of Korean descent

reported having taken a puff. Self-reported puffers

were slightly younger (38.7 vs. 41.2 years old,

p,.001) and more educated (15.2 vs. 14.7 years,

p,.001) than nonpuffers. Puffers also were slightly

more acculturated (.20 vs. .07, p,.001), had less

support for smoking (5.38 vs. 6.00, p,.001), and

reported a greater number of models for smoking

(2.84 vs. 2.54, p,.001) than nonpuffers. Persons

working outside the home were more likely than

others to have taken a puff (54.7% vs. 36.7%,

p,.001), and men were more likely than women to

have taken a puff (79.2% vs. 24.2%, p,.001).

Taking a puff. About 79.2% of men and 24.2% of

women reported having taken a puff at some time in

their lives. Bivariate odds ratios reported in Table 2

computed using logistic regression suggest several

interactions by gender in the association between

predictors and having taken a puff. Older men and

younger women were more likely to report having

taken a puff, and less acculturated men and more

acculturated women reported having taken a puff

(p,.001). Support for smoking (p,.001) and educa-

tional level (p,.05) were associated with having

taken a puff among women, and working outside the

home (p,.001) and the presence of smoking models

(p,.001) were associated with having taken a puff

among men but not women.

To continue smoking or not. What determines

whether those who have taken a puff continue to

smoke or give up smoking? About 41.9% of those

who reported having taken a puff also reported being

current smokers, and 48.1% of men and 25.3% of

women who had taken a puff were current smokers

by CDC criteria. Current smoking status among

respondents who reported ever having taken a puff

was regressed on the same predictors to answer this

question. According to the bivariate odds ratios in

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Table 1. Demographic characteristics of the study sample.a

Characteristic Mean SD % Sample size

Age of respondent, years 40.0 15.0 2,828Years of residence in Korea 23.8 14.2 2,819Years of residence in United States 15.5 8.7 2,819Years of education in Korea 10.4 6.0 2,810Years of education in United States 6.5 7.4 2,810Annual household incomea $51,300 $29,990 1,486Male gender 44.7 2,832Working outside the home 67.4 2,753Born in Korea 93.7 2,821Parents born in Korea 98.5 2,832Interviewed in Korean language 85.4 2,818Marital status 2,700

Single 30.9Married 63.0Widowed 4.5Divorced 1.4Other 0.3

Note. aA large number of respondents refused to provide or did not know information concerning total household income during the pastyear.

4 THE FIRST PUFF

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Table 2, younger persons, less educated persons, and

persons not working outside the home were more

likely to be current smokers among both male and

female puffers. Social support discouraging smoking

also was negatively linked to smoking among both

males and females. Although the presence of smok-

ing models was related positively to current smoking

among puffers, the odds ratio was statistically

significant (p,.05) only among females.

Multivariate statistical analysis strategy

Based on prior research (Hofstetter et al., 2004; Ji et al.,

2005; K. Kim et al., 2000; Lee et al., 2000; Lew et al.,

2001), smoking behaviors clearly differ between Korean

men and women after multivariate statistical controls

were added. For this reason, measures of having taken a

puff and, among those who had ever taken a puff, being

a current smoker by CDC criteria were regressed on

predictors separately for men and women.

Multivariate associations produced similar find-

ings between predictors and taking a puff, although

fewer predictors were statistically significantly

related to taking a puff; this finding was most likely

related to collinearity. Among men, once other

predictors were controlled, age, working outside the

home (p,.001), and the presence of models (p,.001)

were associated positively, and acculturation was

associated negatively (p,.001), with having taken a

puff. Among women, education (p,.05) and accul-

turation (p,.001) were associated positively with

having taken a puff, and social support discouraging

smoking (p,.001) and age were associated negatively

with having taken a puff.

As expected, acculturation appears to influence

taking a puff in the same way that acculturation is

related to more general smoking prevalence

(Hofstetter et al., 2004), according to Table 3. More

acculturated men were less likely to report having

taken a puff than less acculturated men; more

acculturated Korean women were more likely to

report having taken a puff than less acculturated

women. The pattern doubtlessly occurs because all

smokers begin by taking a single puff, traditional

Korean culture encourages male and discourages

female smoking, California has rigorously enforced

legal constraints on public smoking, and California

culture has more liberal gender roles than does

traditional Korean culture.

Predictors of current smoking among those who

report having ever taken a puff are collinear to some

extent since several partial odds ratios are different

than odds ratios based on bivariate relationships.

Age, education, social support discouraging smok-

ing, and acculturation were associated with less

current smoking among male puffers, whereas the

presence of smoking models was associated with

more smoking among males.

Among women who ever took a puff, current

smoking was associated with young age and lower

educational attainment, but not with working out-

side the home or acculturation. Greater social

support discouraging smoking was negatively asso-

ciated with current smoking, and the presence of

smoking models was positively associated with

current smoking among women who had ever taken

a puff. In contrast to expectations based on prior

research, acculturation was not associated positively

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Table 2. Bivariate logistic regression of having ever taken a puff or being a current CDC smoker among puffers on selectedpredictors by gender among Korean American adults residing in California.a,b

Men Women

OR 95% CI OR 95% CI

Having taken a puffAge 1.023*** 1.013–1.033 0.963*** 0.954–0.972Education 0.973 0.924–1.024 1.048* 1.001–1.097Working 2.294*** 1.693–3.108 1.087 0.852–1.386Acculturation 0.422*** 0.313–0.568 2.885*** 2.262–3.680Support 1.002 0.956–1.049 0.894*** 0.862–0.927Models 1.259*** 1.154–1.373 1.026 0.961–1.097

Being a current smoker ModelsAge 0.954*** 0.945–0.964 0.961*** 0.940–0.983Education 0.924*** 0.881–0.970 0.786*** 0.702–0.879Working 0.496*** 0.356–0.690 0.603* 0.373–0.974Acculturation 1.094 0.855–1.398 1.703* 1.091–2.658Support 0.870*** 0.832–0.910 0.882** 0.812–0.958Models 1.047 0.973–1.126 1.205* 1.043–1.392

Note. aValues are bivariate odds ratio between each predictor and having ever taken a puff of a cigarette or being a current smoker andassociated 95% confidence intervals separately for men and women. The lower portion of the table represents estimates only amongrespondents who reported ever having taken a puff. Age and education are coded in years. Working status is coded as ‘‘1’’ for workingoutside the home and ‘‘0’’ for not. Higher support scores indicate social discouragement from smoking, and higher model scores indicategreater number of smoking models. bLevel of statistical significance is estimated using Wald procedures. *p,.05; **p,.01; ***p,.001.

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with smoking among females who had ever taken a

puff in the multivariate model.

Discussion

The present study is the third in a series of studies

(Hofstetter et al., 2004; Ji et al., 2005) drawn from a

sample of adults of Korean descent residing in

California that focuses on tobacco-related behaviors,

using the behavioral ecological model, which empha-

sizes social and situational reinforcers in explaining

behavior. The most important finding in the first

paper was the interaction of acculturation and

gender in smoking prevalence: Highly acculturated

males reported smoking less and highly acculturated

females reported smoking more than less accultu-

rated members of the respective genders. The most

important finding in the second study was that

persons who reported having quit (after having

smoked 100 or more cigarettes) for 90 days or more

was that acculturation was negatively related with

90-day abstinence after statistical controls (including

gender) were applied. Social reinforcers influenced

both smoking and quitting in the predicted directions

in both studies. In the present study, we demon-

strated that, among an exclusive group of persons

who reported ever having taken a puff of a cigarette,

social reinforcers were highly predictive of smoking

status at the time of the interview. This finding

implies that social contingencies are important

factors involved in initiating smoking. However,

these may not be the same social contingencies from

the same people in the social network of a given

smoker.

This study also adds to the evidence that genderserves as a moderating influence for acculturation

processes. Thus we now see that women and men

respond differently to acculturation for smoking, for

cessation, and probably for smoking initiation. This

degree of replication with different groups provides

substantial evidence of construct validity for these

moderating relationships. This, in turn, suggests that

we need to understand the detailed social contingen-cies in the home culture that promote these

differential interactions with a new culture in the

process of acculturation. We also need to understand

the specific social contingencies involved in accul-

turation that promote women to strive for more

equality and sustain them without concurrently

leading them to become more equal with men by

smoking. Understanding the specific contingenciesand their interactions will inform prevention inter-

ventions specific to women immigrants. Failing to

understand these processes will limit prevention

interventions to generic forms that are not likely to

have beneficial effects for women and men under-

going functionally different forms of acculturation.

This study demonstrated that about half of

Californians of Korean descent had a history oftaking an initial puff, and about half the puffers

continued to smoke and half did not. Koreans who

report having smoked 100 cigarettes or more and are

current smokers smoke less (Hofstetter et al., 2004)

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Table 3. Logistic regression of having ever taken a puff or being a current CDC smokers among puffers on selected predictorsby gender among Korean American adults residing in California.a

Men Women

OR 95% CI OR 95% CI

Having taken a puffAge 0.999 0.986–1.014 0.972*** 0.961–0.984Education 0.953 0.902–1.008 0.980 0.929–1.036Working 2.042*** 1.390–3.003 1.395* 1.054–1.847Acculturation 0.527*** 0.366–.759 1.950*** 1.433–2.655Support 0.961 0.911–1.015 0.903*** 0.867–0.940Models 1.203*** 1.096–1.320 1.060 0.983–1.144

x2561.20, p,.001 x25121.94, p,.001Nagelkerke R25.08 Nagelkerke R25.12

Being a current smokerAge 0.940*** 0.927–0.954 0.962** 0.936–0.990Education 0.945* 0.897–0.996 0.769*** 0.678–0.872Working 1.240 0.829–1.854 0.890 0.488–1.623Acculturation 0.454*** 0.325–0.635 1.494 0.815–2.739Support 0.906*** 0.861–0.953 0.891* 0.808–0.983Models 1.116** 1.027–1.214 1.300** 1.101–1.535

x25142.29, p,.001 x2550.52, p,.001Nagelkerke R25.18 Nagelkerke R25.20

Note. aValues are multivariate odds ratio between each predictor and having ever taken a puff of a cigarette or being a current smokerand associated 95% confidence intervals separately for men and women. The lower portion of the table represents estimates onlyamong respondents who reported ever having taken a puff. Age and education are coded in years. Working status is coded as ‘‘1’’ forworking outside the home and ‘‘0’’ for not. Higher support scores indicate social discouragement from smoking, and higher model scoresindicate greater number of smoking models. Missing data have been removed from each regression pairwise. bLevel of statisticalsignificance is estimated using Wald procedures. *p,.05; **p,.01; ***p,.001.

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and are more likely to quit smoking for 90 days or

more (Ji et al., 2005) than California smokers as a

whole. Based on the preceding research, social

support clearly facilitated smoking cessation among

those who met CDC criteria for being a smoker. The

present research extends nonsmokers to include the

48.1% of men and 25.3% of women who took a puff

but never smoked 100 cigarettes and who conse-

quently were not included as quitters in the former

studies.

The findings demonstrate the significance that

social contingencies play in discriminating between

current smokers and nonsmokers among those who

took that first puff. We find that similar contingen-

cies influence experimental puffing and the change

from being an experimenter to being a regular

smoker. This implies the importance of breaking

the pattern of reinforcement among early smokers to

increase the numbers who do not become current

smokers.

The findings suggest this increasingly important

immigrant group warrants closer inspection to better

understand their lifestyle practices and the specific

social contingencies likely to influence first puffs or

experimenting with tobacco and, more important,

those that determine subsequent full-fledged smoking

versus never-smoking. Since about half of the

population did not take an initial puff and since

about half of those who did take an initial puff did

not go on to become current smokers, something

clearly determines prevention of puffs and prevention

of smoking even after experimenting with tobacco.

Identification of specific contingencies that might be

responsible for prevention of puffs and prevention of

smoking is warranted by these observations and

other research. Promising directions to consider are

the degree to which initial experimentation is aversive

(e.g., tastes bad or causes gasping), the degree to

which both close personal friends and family

members model and reinforce avoidance of tobacco,

and the degree to which more general cultural

contingencies serve a moderators (e.g., promotion

of women’s rights) to prevent or promote tobacco.

Preventing the first puff or subsequent established

smoking also would prevent consequential disease

and premature mortality.

Similar to our previous studies of Korean tobacco

use, the present results suggest that social contingen-

cies influence both the first puff and subsequent

current smoking among people of Korean descent in

California. In both logistic regression models, we

used education, work, and acculturation as markers

of relatively general socializing contingencies culture-

wide. These variables and gender may serve as

moderating variables for more proximal contingen-

cies. We used social support and modeling as

markers of more proximal and specific contingencies

derived from a microsocial network such as family

and close friends. By computing these statistical

models for each gender separately, we are able to see

how each interacted with gender.

Consistent with previous studies and the beha-

vioral ecological model, we found that education was

weakly protective against taking a first puff. It was

somewhat more powerful and protective against

women becoming established smokers and almost

neutral for men who become smokers. These findings

suggest that social contingencies above and beyond

educational processes are more powerful possible

‘‘determinants’’ of experimenting and ultimately

establishing smoking than are contingencies from

education in general. They suggest further, however,

a weak moderating effect, in which the protective

influence against established smoking is limited to

females, at least for Korean females residing in

California. Similarly, work outside the home func-

tions in the same direction and increases the risk of

taking the first puff among both genders. Working

outside the home was more powerfully related to first

puff for males than it was for females; but such work

was not significantly related to continued smoking

for either gender. This finding suggests a possible

gender moderating function, in where work is a more

powerful influence on tobacco experimentation

among males than females. This finding has face

validity and justifies further consideration in larger

samples. In traditional Korean culture, middle and

upper class males typically join colleagues for drinks

and smoking after work, but this behavior is

prohibited for women (S. S. Kim et al., 2005).

Both social support that discourages smoking and

the presence of smoking models were related to a first

puff and to current smoking among males and

females in the expected directions after controlling

for other variables. Since each model attained overall

significance, and the directions of partial associations

between predictors and both puffing and current

smoking were parallel, greater confidence can be

assumed for the effects of markers for social

contingencies.

Learning principles and the environment in which

learning occurs, as explained in the behavioral

ecological model (Hovell et al., 2002), play major

roles in smoking behaviors among California resi-

dents of Korean descent. Multiple contingencies

reinforcing or inhibiting smoking are present in the

context of ordinary life among Americans, including

recent immigrants. Social support encouraging or

discouraging smoking and the presence of models

(friends and relatives who smoke) clearly influenced

respondents’ smoking behaviors as did age, educa-

tion, and employment status for some of the

measures. However, the moderating functions appar-

ent for acculturation suggest that social contexts may

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determine when proximal contingencies promote

rather than discourage tobacco use. These contexts

of hierarchical and interacting contingencies are

important to understand to learn why some people

seem to succumb to tobacco-promoting social con-

tingencies whereas others do not.

Acculturation to U.S. society includes adopting

appropriate behaviors and may represent a breaking

away from some traditional Korean norms specific

to gender. Acculturation implies that Korean women

will be exposed to more liberated views of life,

including permissibility of women smoking, whereas

Korean men may be subject to greater social

pressures against smoking than is traditional in

Korea. In California, pressures against smoking in

public accommodations and buildings are codified,

and smokers may be subject to social or legal

penalties. Many of these restrictions are related to

the California anti-tobacco programs, but the precise

way these programs interact with cultural processes

among Korean women and men remains to be

determined.

The acculturation findings among puffers contrast

somewhat with an earlier analysis of the relationship

between acculturation and smoking among all

Californians of Korean descent (Hofstetter et al.,

2004). The directions of association were similar:

Acculturation was associated positively with smok-

ing among women (OR51.643) and negatively

among men (OR50.467). But the partial association

between acculturation and current smoking among

women puffers, though in the hypothesized direction,

did not attain statistical significance (p..05), prob-

ably because of the small number of women smokers

remaining after missing data were removed and

collinearity with other predictors was taken into

account. This finding also enjoys face validity. In

Korea, women are expected to be more deferential to

men in general and not to smoke, whereas men are

expected to be more dominant and to smoke. With a

move to California, it is likely that women who are

relatively acculturated will behave in ways more

equal to men in general and may experiment with

tobacco as a function of acquiring this form of

equality. Men, by contrast, may not encounter

intense social pressure to smoke with male colleagues

at work and elsewhere, thereby making it much less

likely that they will have one puff or become a

regular smoker. However, the efficacy of social

pressure discouraging smoking among both genders

is clear.

The findings in the present study warrant replica-

tion among people of Korean descent in other parts

of the United States where there may not be well-

established and long-lasting anti-tobacco programs.

The California Tobacco Control Program and the

Tobacco-Related Disease Research Program have

established statewide media polices restricting

tobacco advertisement and promoting tobacco con-

trol, policies restricting environmental tobacco

smoke in public buildings, and restrictions on

tobacco industry marketing practices (California

Department of Health Services, 2006; Tobacco-

Related Disease Research Program, 2004). These

programs have changed the culture of California

with respect to tobacco use, and it is not clear how

these practices have influenced Koreans living in

California.

Apparently these programs have not been suffi-

cient to prevent Korean women from initiating

tobacco use more frequently than would be expected

in Korea (Hofstetter et al., 2004). However, they may

have reduced the prevalence of smoking among

Korean women in California compared with what

might be true of Korean women immigrants to other

states lacking strong tobacco control programs. This

possibility warrants investigation to determine

whether statewide tobacco control programs moder-

ate the acculturation processes of ‘‘liberation’’ that

might contribute to higher prevalence of smoking

among Korean women immigrants.

Our data show the necessity of directing programs

to prevent smoking and to encourage quitting in

order to constrain social support for smoking and

limit exposure to models for smoking. The latter may

involve rules about where and when smoking can

occur in the home and in public places where study

participants find themselves. Interventions to prevent

individuals from taking the first puff and to help

smokers to quit may profitably focus on less well-

educated persons. Such interventions may profitably

be tailored directly to more acculturated women and

less acculturated men. Strict enforcement of work-

place antismoking rules may prevent those who work

outside the home from taking the first puff, although

working status does not seem to be related to

continued smoking among those who have taken

the first puff. Finally, language is an important

consideration. Recent immigrants and older persons

speak mostly Korean with limited English; younger

persons speak mostly English with limited Korean.

Future intervention should be delivered in age- and

acculturation-appropriate language.

It is also important to avoid giving up on teenagers

once they have taken the first puff. Other data now

being collected suggest that smoking is extremely

common in urban sites where teenagers of Korean

descent congregate. Stricter enforcement of existing

public antismoking laws in such places would

provide additional disincentives to those experiment-

ing with tobacco.

The behavioral ecological model may serve as a

guide to identify the hierarchical social contingencies

of reinforcement that might explain these results. It is

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especially critical to determine the precise social

events that might account for these differential

responses to tobacco use between men and women

of Korean decent, in order to inform gender-specific

interventions. Such findings also might confirm

general axioms that could inform specific interven-

tions for other immigrant populations, if not the

general population. Such research is critical to

further decrease tobacco use and its consequential

disease burden on the populations of California, the

United States, and the world.

Generalizations are bound by time and space.

Although about one-third of the Korean population

in the United States resides in California, the present

findings may not generalize to all people of Korean

descent in the United States. Given that telephone

surveys cannot contact persons who do not have

residential landline telephones, no records are avail-

able for people with unlisted or cell phone numbers,

and the small proportion of Koreans within the

larger population precludes efficient random-digit-

dialing sampling, doubts may be raised concerning

the study’s external validity. However, demographics

in the 2000 U.S. Census closely matched demo-

graphics in our survey.

The present analyses came from a cross-sectional

survey and as such cannot provide direct estimates of

change over time or the causal variable likely to be

responsible. Thus the findings here should inform

longitudinal designs that can assess change and

possible determinants of change among Korean

Americans. The present study did not include

measures of specific social processes that might

account for the differences in tobacco use patterns

among men and women as they are acculturated.

Future studies should determine how Korean men

and women experience different social processes

during acculturation.

Acknowledgments

This research was supported by funds provided by the Tobacco-

Related Disease Research Program grant 9RT-0073 to C. Richard

Hofstetter. The authors thank the California Tobacco-Related Disease

Research Program and Korean study participants in California for

their support in conducting this study.

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