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: [email protected]
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.
6 THE FIRST PUFF
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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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