Multilevel Factor Influence on Alternative Tobacco Product Use Among U.S. Foreign-Born Residents

Abstract

Background: In the United States, the use of alternative tobacco products (ATPs), such as e-cigarettes, cigars, little cigars, hookah, or smokeless tobacco, has been rising even as conventional cigarette smoking continues decreasing. Broadly speaking, smoking behaviors are influenced by multiple factors at the intrapersonal, interpersonal, organizational, and community levels, including individual harm perceptions toward ATPs, peer and family use of tobacco products, ATP marketing and promotions targeted at specific races and ethnicities and acculturation. However, data on ATP use among U.S. foreign-born residents are limited and factors influencing ATP use among this population are not yet well understood. The primary purpose of this dissertation was to understand multilevel factors, addressed in Social Ecological Model (SEM), that influence ATP use among U.S. foreign-born residents. Purpose: The aim of study one was to assess the association between acculturation, harm perceptions, and peer and family use of tobacco products, and ATP use among U.S. foreign-born residents using waves 3 and 4 of the Population Assessment of Tobacco and Health (PATH) Study. The aim of study two was to assess the association between acculturation, peer and family use of ATPs and exposure to ATP advertisements, marketing and promotions, and ATP use among U.S. foreign-born residents using the same dataset. The aim of study three was to obtain a deeper understanding of how multilevel factors influence ATP use among non-U.S. citizen Korean residents. Methods: In studies one and two, quantitative data analyses were conducted from 2,507 foreign-born adult residents using PATH waves 3 and 4. Chi-square test and multivariate logistic regressions were used, and moderation and mediation analyses were conducted. In study three, twenty-one non-U.S. citizen Korean residents who currently or formerly smoked or used any ATPs and were aged 18-39 years in District of Columbia (DC), Maryland (MD) or Virginia (VA) completed 60-minute semi-structured in-depth interviews. Interviews were transcribed verbatim, coded, and analyzed thematically. Findings: In study one, findings suggest that certain acculturation factors predicted current and lifetime ATP use among U.S. foreign-born residents. For example, less acculturated foreign-born residents in the U.S. perceived ATPs as very or extremely harmful to their health and were less likely to use ATPs compared to the U.S.-born counterparts. In study two, findings indicated that less acculturated foreign-born residents were less likely to have peer and family who use ATPs and to be exposed to ATP advertisements, marketing and promotions compared to the U.S.-born counterparts. In study three, e-cigarettes were the most popular ATPs with participants, followed by hookahs and heated tobacco products (specifically IQOS). Participants showed more ambivalence or regarded e-cigarettes and hookahs as less harmful than conventional cigarettes. Additionally, smoking initiation was influenced mainly by peers who smoked. Conclusion: Multiple factors at different determinant levels influence tobacco product use behaviors among U.S. foreign-born residents. Acculturation factors, along with harm perceptions, peer and family influence, and ATP advertisements, marketing, and promotions exposure, seem to influence ATP use among U.S. foreign-born residents. Implications: This research calls for culturally tailored interventions and smoking cessations for U.S. foreign-born residents. Future research should investigate multiple tobacco product use among foreign-born residents as well as how the country of origin influences ATP use behaviors.