Factors affecting American Indian adolescent tobacco use

Addictive Behaviors 30 (2005) 889 – 904

Factors affecting American Indian adolescent tobacco use ManSoo Yu*, Arlene Rubin Stiffman, Stacey Freedenthal George Warren Brown School of Social Work, Washington University, Campus Box 1196, One Brookings Drive, St. Louis, MO 63130, United States

Abstract The present study merged problem behavior and social ecological theories to examine how mental health and environmental factors, including culture, were associated with American Indian youth tobacco use. A stratified random sample of 205 reservation and 196 urban American Indian adolescents living in a Southwestern area was interviewed in 2001. Two-thirds of the reservation youth and half of the urban youth in this sample reported lifetime tobacco use. Logistic regression showed that, when controlling for age and location, a mental health factor (substance abuse/dependence) and environmental factors (e.g., family members’ mental health problems and peer misbehavior) were significant predictors of American Indian adolescent tobacco use. Cultural factors and location (reservation vs. urban) were not significant predictors of their tobacco use. Therefore, environmental and mental health factors should be assessed for and incorporated into tobacco use intervention and prevention plans for American Indian youth in both reservation and urban areas. D 2004 Elsevier Ltd. All rights reserved. Keywords: Tobacco use; Mental health; Environment; American Indian Adolescents

1. Introduction American Indian and Alaska Native adolescents have the highest lifetime cigarette use rates among all ethnic groups. These rates of 61.1% are 1.5–2 times the rates for every other

* Corresponding author. Tel.: +1 314 9358173; fax: +1 314 9358511. E-mail address: [email protected] (M.S. Yu). 0306-4603/$ - see front matter D 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2004.08.029

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ethnic/racial group (Substance Abuse and Mental Health Services Administration (SAMHSA), 2002). The high rates are true for both reservation and nonreservation 8thand 12th-grade Indian students (Beauvais, 1992). These high rates of tobacco use in American Indian and Alaska Native youth lead to serious health problems, including cough and phlegm production, increase in the number and severity of respiratory illnesses, and reduced rates of lung growth and function (Association of American Indian Physicians (AAIP), 2001; Centers for Disease Control and Prevention (CDC), 1994). As well, an average of two out of every five American Indian smokers die of tobacco abuse (AAIP, 2001). In particular, cardiovascular disease is the leading cause of death and lung cancer is the leading cause of cancer death among American Indians and Alaska Natives (U.S. Department of Health and Human Services (USDHHS), 1998). The death rate among American Indians related to tobacco abuse is twice that of the US population (AAIP, 2001). There are a number of studies of American Indian youth’s tobacco use (Beauvais, 1992; Federman, Costello, Angold, Farmer, & Erkanli, 1997; Kegler, Cleaver, & Yazzie-Valencia, 2000; LeMaster, Connell, Mitchell, & Manson, 2002; Nelson, Moon, Holtzman, Smith, & Siegel, 1997; Unger et al., 2003). Concerning mental health, Federman et al. (1997) posited that the use of substances, including tobacco, was associated with conduct disorder, but was not related to depression. Many studies examine environmental variables. Kegler et al. (2000) pointed out family influences (e.g., modeling of smoking behavior) on American Indian adolescent cigarette smoking. LeMaster et al. (2002) described death, loss and other stressful events as the risk factors for cigarette use. Nelson et al. (1997) found that possible reasons for adolescent tobacco use included modeling by familial behaviors and peer pressure. Due to cultural issues, American Indian adolescents might be confronted with more environmental influences encouraging tobacco use than non-American Indian populations, in that many of them need to use tobacco in their traditional ceremonies. For instance, 66% of ceremonial and traditional tobacco users among American Indian youth were non-smokers (The Great Epicenter News, 2001). Further, cigarettes among American Indians are used for medical purposes and serve a major role in burial services (Pego, Hill, Solomon, Chisholm, & Ives, 1995). Besides, tobacco industries commonly utilize American Indian cultural symbols for promoting their product to American Indians and Alaska Natives (USDHHS, 1998). On the other hand, despite the cultural emphasis on tobacco use, a strong cultural identity has been identified as a protective factor affecting substance use (Manson, Shore, Baron, Ackerson, & Neligh, 1992). Studies looking at demographics found that male gender, American Indian race, and higher age were significantly associated with adolescent tobacco use (Federman et al., 1997). Beauvais (1992) found that reservation youth used significantly more tobacco than nonreservation youth, while Unger et al. (2003) reported that there was no difference in smoking prevalence between youth from the two areas. The high rates of tobacco use and the health problems in American Indian youth require the study of factors that affect such use. Yet, most of the aforementioned studies of American Indian adolescent tobacco use have examined only a few of the known predictors and done so in largely bivariate analyses. On the basis of the merging of two theories: Problem behavior

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theory (PBT, Jessor & Jessor, 1977) and social ecological theory (SET, Bronfenbrenner, 1979), this present study identifies multiple and joint factors associated with American Indian adolescent tobacco use. According to PBT, adolescents engaging in one type of problem behavior are more inclined to undertake other problem behaviors (Jessor, Chase, & Donovan, 1980). For instance, tobacco-using adolescents may have other problem behaviors (e.g., conduct disorder). On the other hand, SET underlines the relationships between environmental factors (e.g., the family, peers, schools and communities) and problem behaviors

Fig. 1. Model of the relationship between the key theoretical variables and American Indian adolescent tobacco use.

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(Bronfenbrenner, 1979). Although not identified particularly by either theory, culture can be conceptualized as an environmental factor and we include it as such. Fig. 1 presents our unique merging of the key theoretical concepts from both theories. We hypothesize that American Indian youth tobacco use (outside of traditional ceremonial use) will be explained by the theoretical predictors of mental health (e.g., conduct disorder, alcohol abuse/dependence and substance abuse/dependence), environment (familial, social and cultural environment), and demographics (age, gender and location). We also address three research questions: (1) What are the prevalence, onset age, frequency and amount of tobacco use for urban versus reservation adolescents? (2) What is the relationship between the key theoretical variables (mental health and environment) and tobacco use? and (3) What might constitute potentially modifiable risk factors associated with such use?

2. Methods This paper is based on data from the American Indian Multisector Help Inquiry (AIM-HI), a NIDA-funded study of service use and drug-use information in two American Indian populations, one urban and one reservation-based, over a 5-year period. The urban youth live in a large city. Many of the urban youth have familial and cultural ties to one of several reservations three to 7 h away. The reservation area is peri-urban, in that the closest city has grown towards it in the last two decades. Its size and location are typical of the majority of reservation areas. The reservation youth live in a community of 6000 on more than 55,000 acres, within community of the city where the urban youth live. To ensure confidentiality of tribe and subjects, the AIM-HI study does not report the name of the reservation or urban area. Internal Review Boards at Washington University, the reservation’s tribal council, and the urban school district reviewed, shaped, and approved the consent and protection procedures. Personnel from local American Indian educational and health services made the initial contact with the randomly selected families who had adolescent children, notifying them about AIMHI and encouraging their participation. Families were asked to return a fold-over, prestamped postcard signed by the youth and a guardian. In the card, the guardian either consented to or refused the research. Families who did not actively refuse were contacted directly by the interviewers. Only six families or youth refused in each area. 2.1. Subjects A sample of 401 youth (205 reservation and 196 urban youth), aged 13–19, was interviewed in person through a two-stage method. As shown in Fig. 2, first, a sample of 300 reservation-based youth from the complete tribal enrollment list, and 300 urban-based youth from school district records including those who had dropped out was randomly selected for a brief interview. These documents assured that the selection was representative of all the American Indian youth in both areas. Only one child per household was enrolled. Second, of the youth who participated in the brief interview, about 150 from each area were randomly

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Fig. 2. Flow chart of the sampling.

selected for the long interview. To comprise the final sample of about 200 from each area, the study added 50 youth in each area from those not randomly selected. These 50 youth enriched the sample in each area with more youth likely to need services for mental health problems because they had scores on the brief screening instruments, the Achenbach Youth Self Report (TN63) (Achenbach, 1991) and the Columbia Impairment Scale (N15) (Bird et al., 1993) that indicated they might have such problems (see Fig. 2). 2.2. Interview procedures The reservation and urban areas each had a field supervisor from the local community whose responsibility was to assure culturally sensitive interaction with the community and supervise all interviews. The field supervisors and most of the interviewer were American Indian. AIM-HI held a six-day session for the two field supervisors and a 4-day training session for the 11 interviewers. The training session included topics such as interviewing, crisis intervention, risk assessment, confidentiality, computer usage, and documentation. All interviews were administered face-to-face using a computer-assisted system, with interviewers reading questions from and entering responses identified only by code numbers into a laptop computer. Interviewers were required to accurately and smoothly complete a practice interview prior to entering the field. Supervisors reviewed audiotapes of each interviewer’s entire first two interviews and gave immediate feedback. They reviewed audiotapes only of selected sections for later interviews. In 2001, trained interviewers contacted and administered a brief interview. Interviewers first explained the brief interview and the full study, and obtained parent/guardian and youth consent (if not already signed). For the brief interview, youth were offered a T-shirt with an AIM-HI logo designed by a local American Indian artist. If the youth met either random selection (150 youth for each area) or high-need enrichment criteria (additional 50 youth who were likely to have mental health problems for each area), the interviewer scheduled the long

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interview, for which youth were paid an additional $25.00. Of the youth who completed the brief interview and were scheduled for the long, 2.7% of the youth refused or had a parent withdraw consent. 2.3. Instruments Only selected measures from the much larger AIM-HI study were used for this paper. 2.3.1. Tobacco use Interviewers used portions of the National Institute of Mental Health’s Diagnostic Interview Schedule (DIS-IV) (Robins, Helzer, Croughan, & Ratcliff, 1981) to measure lifetime tobacco use, which consisted of cigarettes, cigars, pipes, and snuff/chewing tobacco. Participants were asked, bHave you ever smoked cigarettes, cigars, a pipe, and/or used snuff/ chewed tobacco?Q Responses to these four questions were coded dichotomously (yes/no). Tobacco used exclusively for traditional ceremonies was excluded from the diagnostic criteria. 2.3.2. Mental health problems Questions concerning depression, conduct disorder, and substance (alcohol and other drugs) abuse or dependence came from the DIS-IV (Robins & Helzer, 1994). The DIS section on alcohol and drug abuse or dependence was modified to exclude drugs used exclusively for spiritual or healing ceremonies. The DIS allows two separate operationalizations of mental health problems: (1) A diagnosis of disorder based on computer algorithms that combine symptoms according to the criteria in DSM-IV; and (2) A count of serious symptoms (e.g., those lasting 2 weeks or more, or those which interfere significantly with the youth’s life). 2.3.3. Family members’ mental health problems To assess family members’ mental health problems, youth were asked if their parents, brothers, and/or sisters had problems like: talked to a doctor or counselor about emotional or mental problems; couldn’t work or was hospitalized because of emotional or mental problems; suffered depression; attempted suicide; had drinking and/or drug problems; were not able to hold a job because of having trouble with police or fighting; and/or had a gambling problem in their life (Robins & Helzer, 1994). Responses to these 10 questions with yes or no were summed. Cronbach’s alpha coefficient was 0.63 for this study and previously demonstrated a Cronbach’s alpha of 0.78 (Stiffman, 1989a, 1989b). 2.3.4. Family life stressful events To measure family life stressful events, respondents were asked if they had problems in their family during the past six months: arguing or fighting in the home; money worries; family member’s serious illnesses; a family member’s alcoholism or drug abuse; problems with police; threats to self or family members; and/or beating or killing of friends or

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family members in the last 6 months (Stiffman, Hadley-Ives, Elze, Johnson, & Dore´, 1999). Positive responses to these nine questions were summed. Cronbach’s alpha coefficient for the scale in this study was 0.65 and 0.70 in other studies (Stiffman, Earls, & Chueh, 1992). 2.3.5. Peer misbehavior Peer misbehavior was assessed by asking how many of the youth’s acquaintances and friends (people about their age) had trouble with the police or juvenile officer; had babies or fathered babies; used alcohol, tobacco, marijuana, inhalants, and/or other illegal drugs; were both unemployed and out of school; sold drugs or marijuana, attempted or committed suicide; and/or belonged a gang in their life (Stiffman et al, 1999). Responses on a 5-point scale (bnone,Q ba few,Q babout half,Q bmost,Q ballQ) to these 11 questions were summed. Cronbach’s alpha coefficient was 0.84. 2.3.6. Neighborhood or school problems Neighborhood problems were assessed by asking the degree to which the respondents’ neighborhood had drug dealing, shooting, murders, abandoned buildings, neighbors on welfare, homeless people in street, and/or prostitution in the past six months (Hadley-Ives, Stiffman, & Dore, 2000). School problems were measured by asking the degree to which their schools had drug dealing, shooting, stabbing, knifings, teachers injured by students, school equipment damaged, discrimination, fighting, carrying weapons, using drugs on campus, and/or jumping kids into gangs (Hadley-Ives et al., 2000). Responses on a 3-point scale (bnone,Q bsome,Q ba lotQ) to these 15 questions (seven questions for neighborhood problems and eight questions for school problems) were summed. Cronbach’s alpha coefficient was 0.81. 2.3.7. Cultural activities American Indian cultural activities were measured with questions modified from the Orthogonal Cultural Identity Scale (Oetting & Beauvais, 1991). Adolescents ranked their involvement in 11 American Indian traditions (memorials/ feasts, Powwows/dances, giveaways, healing ceremonies, sweats, religious events, naming ceremonies, talking circles, spiritual running, other traditional activities and private American Indian spiritual activities such as using sweetgrass, juniper, sage, and corn pollon/meal). Responses to these questions on a 4-point scale (bnot at all,Q ba little,Q bsome,Q ba lotQ) were summed. Cronbach’s alpha coefficient was 0.86 in this sample. 2.3.8. Cultural pride American Indian adolescents were asked three questions to measure cultural pride, bHow proud are you of your American Indian ancestry?Q bHow important is being spiritual to you?Q bDo you feel spiritual values are a part of your life?Q These questions were also modified from the Orthogonal Cultural Identity Scale (Oetting & Beauvais, 1991). Responses on a 4-point scale (bnot at all,Q ba little,Q bsome,Q ba lotQ) were summed. Cronbach’s alpha coefficient was 0.73.

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2.4. Statistical analysis Univariate analysis was used to calculate frequency of tobacco use. Chi-square and independent t-tests evaluated the relationships between location (reservation vs. urban) and all independent variables (demographics, mental health, familial, social and cultural factors); the prevalence, average onset age and average daily amount of tobacco use; and the associations between all the independent variables and tobacco use. To determine which factors contributed to American Indian adolescent tobacco use, multiple logistic regression analysis evaluated the odds ratios of tobacco use. The researchers weighted the data to recreate a sample N equivalent to that in the original random sample of 567 and with the same balance of high-need youth, because the study had deliberately enriched the sample with 50 high-need youth in each area. To do this, two proportions were calculated based on the ratio of youth in the initial larger random sample (n=567) to those in the smaller over-sampled high-need group (n=401): one for youth who met high-need criteria (203/182) and one for those who did not meet high-need criteria (364/ 219). These weights were 1.1 for the youth who did meet high-need criteria and 1.7 for the youth who did not meet high need oversampling criteria. This weighted N was used to calculate all rates in this study. All analyses were completed using STATA 7.0 (STATA, 2001). STATA software is especially appropriate for analyzing weighted data because it yields correct standard errors for weighted data.

3. Results 3.1. Descriptive information Urban youth were significantly older (about 8.4 months on average) than reservation youth. Slightly more of the youth were female than male in both areas. As shown in Table 1 below, significantly more reservation than urban youth had conduct disorder (26% vs. 18%) and alcohol abuse/dependence (16% vs. 7%), but there were no differences in depression and substance abuse/dependence. Further, reservation youth had significantly more misbehaving peers than urban youth (12 vs. 10). In contrast, urban youth had significantly more neighborhood or school problems (6 vs. 5) and cultural pride (7 vs. 6). There were no significant differences in number of family members with mental health problems, family life stressful events and cultural activities between two locations. 3.2. The prevalence, onset age, frequency and amount of tobacco use Over half (59%) of American Indian adolescents living in these Southwestern urban and reservation areas reported some type of tobacco use (not counting those who smoked pipes only in traditional ceremonies) in their life. Specifically, about one in two smoked cigarettes,

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Table 1 Descriptive information Characteristics

Reservation (n=205)

Urban (n=196)

Demographics Gender Male Female Age

45.9% 54.2% 15.3

44.0% 56.0% 16.0

v 2=0.13

Mental health Conduct disorder Depression Alcohol abuse/dependence Substance abuse/dependence

26.3% 20.4% 16.2% 29.4%

18.2% 16.2% 7.2% 22.2%

v 2=3.81* v 2=1.16 v 2=7.78** v 2=2.65

t=4.54****

Familial environment Number of family members with mental health problems Family life stressful events

2.3

1.9

t=1.84

2.0

1.9

t=0.37

Social environment Peer misbehavior Neighborhood or school problems

11.7 4.8

9.7 5.7

t=2.98** t=2.21*

8.3 6.1

9.3 6.7

t=1.48 t=2.59*

Cultural environment Cultural activities Cultural pride * pb0.05. ** pb0.01. **** pb0.0001.

one in five smoked cigars, one in four smoked pipes, and one in twenty used snuff or chewed tobacco. Significantly more reservation than urban youth had used tobacco (65% vs. 54%) (See Table 2). Reservation youth were also significantly more likely to have smoked pipes than urban youth (30% vs. 20%). Specifically, there was a significant difference in the use of pipes for casual or recreational use (not for traditional ceremonies) between two locations. About 27% (nine in ten of the 30% who were pipe users) of reservation youth and 13% (two in three of the 20% who were pipe users) of urban youth smoked pipes casually or recreationally. There were no significant differences in use of cigarettes (64% for the reservation youth vs. 55% for the urban youth), cigars (19% in each area), and snuff or chewing tobacco (7% for the urban youth vs. 4% for the reservation youth). Respondents from both locations averaged smoking initiation around 14 years old. As shown in Table 3 below, for reservation youth, cigarette use came earliest at 12.3 years old, followed by smoking pipes at 12.9 years old, and then smoking cigars and using snuff/ chewing tobacco at 14 years old. On the other hand, for urban youth, using snuff or chewing

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Table 2 The prevalence of tobacco use Types of tobacco use

Reservation (n=205) %

Urban (n=196) %

v2

Tobacco use Cigarettes Cigars Pipes Casual/recreational use only Traditional ceremonies use only Snuff/chewing tobacco

64.5 63.6 19.4 30.4 89.3 10.7 4.0

54.0 55.2 19.1 19.8 65.7 34.3 6.7

4.38* 2.77 0.01 5.93* 5.72* 1.30

* pb0.05.

tobacco came earliest at 11.2 years old, followed by smoking cigarettes at 12.7 years old, smoking pipes at 13.2 years old, and then smoking cigars at 14.3 years old. In particular, urban youth initiated use of snuff or chewing tobacco about three years earlier than reservation youth (14 vs. 11.2 years old). There were no significant differences in average age of onset for smoking cigarettes, cigars, and pipes. The majority of American Indian youth used tobacco less than 1–2 days a week (see Table 4). However, in both locations, 16–18% of youth who smoked cigarettes and/or used snuff or chewing tobacco did so every day. Reservation American Indian youth who used tobacco averaged daily use of 3.7 cigarettes, 3.6 pipes and 1.6 cigars, while urban youth averaged daily use of 5.0 cigarettes, 2.9 pipes, 2.6 snuff or chewing tobacco and 1.2 cigars (see Table 5). There were no significant urban and reservation differences in average daily amount of all types of tobacco. 3.3. Bivariate relationships between demographics and key theoretical variables, and tobacco use Tobacco using youth were significantly older than non-using youth (15.9 vs.15.3); but there was no significant difference in gender between tobacco users and nonusers (see Table 6). Tobacco users had significantly more mental health problems than nonusers: conduct disorder (32% vs. 8%), alcohol abuse/dependence (19% vs. 2%) and substance abuse/ dependence (38% vs. 8%). There was no significant difference in depression between tobacco users and nonusers.

Table 3 Average onset age of tobacco use Types of tobacco use

Reservation (Mean) (n=205)

Urban (Mean) (n=196)

t

Cigarettes Cigars Pipes Snuff/chewing tobacco

12.3 14.0 12.9 14.0

12.7 14.3 13.2 11.2

1.04 0.55 0.60 3.22**

** pb0.01.

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Table 4 Frequency of tobacco use during using the most Types of tobacco use Cigarettes

Cigars

Pipes

Snuff/chewing tobacco

Frequency of tobacco use (%) Almost every day 3 or 4 days a week 1 or 2 days a week Less than 1 or 2 days Almost every day 3 or 4 days a week 1 or 2 days a week Less than 1 or 2 days Almost every day 3 or 4 days a week 1 or 2 days a week Less than 1 or 2 days Almost every day 3 or 4 days a week 1 or 2 days a week Less than 1 or 2 days

a week

a week

a week

a week

Reservation (n=97)

Urban (n=56)

16.5 12.8 19.5 51.2 2.0 2.0 13.9 82.1 17.4 10.7 23.1 48.8 0.0 0.0 0.0 100

15.8 11.5 17.3 55.4 0.0 2.1 15.8 82.1 18.2 9.1 20.5 52.2 0.0 9.1 6.1 84.9

Tobacco users had significantly more family environment problems: family members with mental health problems (2.4 vs. 1.6) and family life stress (2.3 vs.1.5). Similarly, they had more peer misbehavior (13 vs. 7). However, there were no significant differences in neighborhood/school problems and cultural environment. 3.4. Multivariate predictors of American Indian adolescent tobacco use Table 7 illustrates the results of multiple logistic regression analysis regarding factors bivariately associated with American Indian adolescent tobacco use. American Indian adolescent tobacco use had positive relationships with age, substance abuse/dependence (a mental health problem), family members’ mental health problems (a familial environment) and peer misbehavior (a social environment). However, location (reservation vs. urban) was not a significant factor affecting adolescent tobacco use, even though earlier bivariate analyses showed significant differences in tobacco use by location. The model was significant, v 2 (5, N=390)=55.79, pb0.0001. Table 5 Average daily amount of tobacco use Types of tobacco use Cigarettes Cigars Pipes Snuff/chewing tobacco

Average amount of tobacco use (Mean) Reservation (n=48)

Urban (n=26)

3.7 1.9 3.6 0.0

5.0 1.2 2.9 2.6

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Table 6 The demographics and key theoretical variables for tobacco users and nonusers Characteristics

Tobacco users (n=244)

Tobacco nonusers (n=156)

Demographics Gender Male Female Age

43.0% 57.0% 15.9

48.0% 52.0% 15.3

t=3.45***

Mental Health Conduct disorder Depression Alcohol abuse/dependence Substance abuse/dependence

32.1% 18.6% 18.6% 38.3%

8.2% 17.4% 1.9% 8.0%

v 2=27.48**** v 2=0.09 v 2=20.99**** v 2=36.81****

v 2=0.92

Familial Environment Number of family members with mental health problems Family life stressful events

2.5

1.6

t=4.89****

2.3

1.5

t=4.04****

Social Environment Peer misbehavior Neighborhood/school problems

13.0 5.6

7.6 4.9

t=8.93**** t=1.85

9.1 6.4

8.3 6.4

t=1.13 t=0.01

Cultural Environment Cultural activities Cultural pride *** pb0.001. **** pb0.0001.

Table 7 Multiple logistic regression analysis with key theoretical predictors for tobacco use in American Indian adolescents in a Southwestern area (N = 390)a Variable

Beta coefficients

S.E.

p value

Odds ratio

95% Confidence interval

Demographic factors Age Location (Reservation=1)b

0.16 0.42

0.08 0.25

0.046 0.097

1.17 1.52

1.00–1.37 0.93–2.51

Mental Health Factors Substance abuse/dependence

0.99

0.36

0.006

2.70

1.33–5.45

0.17

0.07

0.019

1.18

1.03–1.35

0.10

0.02

0.000

1.11

1.06–1.16

Environmental factors Family members’ mental health problems Peer misbehavior a b

N = 390 out of 401 in the original data set is equal to N = 552 out of 567 in the weighted data set. Location retained in final model due to potential confounding.

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Specifically, for each year of age increase, youth were 17% more likely, in terms of odds, to use tobacco. When controlling for age, substance abuse/dependence, familial and social problems predicted additional variance. For each unit increment in substance abuse/dependence, youth were 170% more likely to use tobacco. For each unit increment in family members’ mental health problems, youth were 18% more likely to use tobacco. For each unit increment in peer misbehavior, youth were 11% more likely to use tobacco. 4. Discussion This paper adds to the increasing recognition that tobacco use is a serious health problem issue for American Indian adolescents (Beauvais, 1992; LeMaster et al., 2002; SAMHSA, 2002). This paper reveals that American Indian adolescents living in the Southwestern area are high users of tobacco. Over half (59%) of American Indian adolescents in both reservation and urban locations reported tobacco use in their life outside of traditional ceremonies. Consistent with a previous study (Beauvais, 1992), reservation youth used significantly more tobacco than urban youth. In particular, they used significantly more pipes (not counting those who only smoked pipes in traditional ceremonies). On the other hand, urban youth began to use snuff or chewing tobacco about three years earlier than reservation youth. Yet, location was not actually a factor affecting adolescent tobacco use in the regression model. This paper merges the key theoretical factors affecting American Indian adolescent tobacco use from problem behavior theory (Jessor et al., 1980), which underlines tobacco users’ engagement with other problem behaviors and social ecological theory (Bronfenbrenner, 1979), which emphasizes the relationships between environment and problem behaviors. The multivariate results support problem behavior theory indicating that tobacco users had significantly more mental health problems (e.g., substance abuse/dependence) than nonusers. As well, social ecological theory predicts such users also had more familial and social problems (e.g., family members’ mental health problems and peer misbehavior) than nonusers. However, although we posited in our merged theoretical model (see Fig. 1) that cultural factors were an element of environment, American Indian cultural factors were not related to adolescent tobacco use. The study had several limitations. Foremost among them is the confinement of the study to one reservation and one urban area. Further, these reservation and urban youths are both from acculturated populations with relatively easy access to urban centers rather than from isolated, more traditional American Indian communities. On the other hand, the similarities enhance the potential generalizability of results because 39% of American Indians and Alaska Natives are under age 20, and most belong to a mid- to small size peri-urban reservations (U.S. Census Bureau, 2001). Another limitation of this study was its cross-sectional nature, which restrains any interpretation of causality. Regardless of any limitations, the study has important implementations for future research and potential interventions. Adolescence is a key developmental stage during which risky

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health behaviors are initiated, so it is key time for prevention efforts (LeMaster et al., 2002; National Cancer Institute (NCI)., 2001). According to Stone and Kristeller (1992), 90% of adult smokers initiate smoking by age 19. For that reason, prevention of tobacco use during this vulnerable age is critical, as cigarette smoking is the single most preventable cause of disease and death in the United States (NIDA, 1999). As we stated earlier, family and peer environments, and substance abuse/dependence are associated with adolescent tobacco use. Therefore, these problems should be assessed for and incorporated into tobacco use intervention and prevention plans for American Indian youth. For example, many intervention and prevention research studies show that successful programs for adolescents with tobacco use involve families and/or peers in treatment (Newcomb & Bentler, 1989; Plaut & Kelly, 1989; Reddy et al., 2002; Storr, Ialongo, Kellam, & Anthony, 2002; Walsh et al., 2002). The relevance of these aspects for prevention is consistent with other findings that external support systems in the school or American Indian communities that strengthen coping efforts might protect highly stressed adolescents from adverse outcomes (Flynn et al., 1997; Horn, Fernandes, Dino, Massey, & Kalsekar, 2002; Myers, Brown, & Kelly, 2000; Reddy et al., 2002; Storr et al., 2002). Future research should integrate longitudinal studies that allow for studies of the causal variables influencing smoking stages over time, as well as investigation of various trajectories of smoking uptake and nicotine dependence (Lloyd-Richardson, Papandonatos, Kazura, Stanton, & Niaura, 2002).

Acknowledgements The author is grateful to Dr. Ed Spitznagel for invaluable statistical suggestions. This study was supported by NIDA grant R01 DA13227.

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