To the best of our knowledge, this is the first study to qualitatively examine contextual factors influencing culturally-specific tobacco use among South Asians in ethnic enclaves in the United States. Our findings confirm local survey data from other common destinations of South Asian migration in the U.S., demonstrating a high use rate of a considerable number of culturally-specific products among this population.[20
] Not only is this information pivotal for addressing high rates of tobacco-related disease in the Indian subcontinent, it informs the design of interventions that may be applicable to migrant South Asian populations. Similar to research conducted in other ethnic enclaves, we found use was common even among individuals born outside of South Asia.[34
] Our results parallel prior studies outside of the United States finding incomplete or inaccurate knowledge of health risks and perception of benefits attributable to product use.[17
] For instance, South Asians in England, who have high rates of culturally-specific tobacco use, generally have low levels of knowledge regarding the health risks imparted by these products.[34
] Our study also identified unique perceived benefits, such as nutritional value and aiding sleep. Despite scientific evidence to the contrary, these findings suggest that these beliefs are strong influences on culturally-specific tobacco use among South Asian migrants.
Perhaps more important are the social and cultural influences on South Asian tobacco behavior. In contrast to tobacco use in South Asia, using culturally-specific items to maintain traditions, engage in celebration, and socialize with members of similar ethnic backgrounds—in a new dominant society—were frequently cited by respondents as reasons for use. In terms of religion, our results mirror research in the United Kingdom showing smoking, especially hookah
, is more acceptable among South Asian Muslims, while elucidating the value of smokeless paan
] Especially among children of immigrants, adopting patterns of “native” behavior symbolizes a surrogate and powerful connection to cultural roots.
Our most significant new finding was the role of culturally-specific tobacco use in the expression of South Asian ethnic identity, differentiating this community from mainstream society and other minority groups. South Asians are commonly conferred a privileged ascription of high education and economic success. Respondents repeatedly reported that use of South Asian products, especially among groups, was a mechanism to outwardly display ethnic pride.
The combination of intragroup (maintenance and preservation of traditions and celebrations) and intergroup (expression and distinction of ethnic identity) influences on tobacco use among South Asians in the United States has important implications for tobacco control. Most epidemiological studies do not survey ethnic-specific products, and thus the true prevalence of tobacco use is underestimated for certain groups. Tobacco products hold considerable social and cultural value for specific communities, often creating different motivations for use. Tobacco control efforts addressing culturally-specific tobacco use must take into account their socio-cultural function, especially to establish a unique identity relative to other minority groups and mainstream society.
This study also has implications for global tobacco control. South Asians are the second largest global population with over 20 million individuals living outside of the Indian subcontinent.[16
] Agencies such as the World Health Organization have rigorously developed instruments to assess prevalence of a variety of tobacco products indigenous to specific regions. These surveys serve as an important resource for measuring (and comparing) tobacco use among immigrant communities by enabling identification of culturally-specific tobacco and relevant covariates. However, these country-specific instruments are unable to assess the social function of tobacco use for preserving and expressing ethnic identity in a new host society. As the United States and other destination countries experience a large influx of immigrants—bringing with them their native behaviors and beliefs—culturally-framed tobacco behaviors must be understood by tobacco control researchers to create appropriate survey constructs which empirically assess prevalence and contribution of socio-cultural factors and inform targeted intervention strategies.
These issues are not limited to South Asians in the United States; the sacred nature of tobacco has been described among indigenous populations in North America.[37
] Among Southeast Asian and Pacific Islander populations, chewable concoctions of combined betel-nut and tobacco are popular, whereas for groups of Middle Eastern origin, the use of the hookah for smoking tobacco is a popular practice.[27
] While social function
related to tradition has been explored, less is known about use related to expression
of ethnic identity. This role for tobacco may also hold true for other small and understudied migrant populations, especially for those with positive ascriptions among the dominant society.
With regard to tobacco control interventions, there is a need to increase awareness among health care providers serving large South Asian populations about the common use of these products and associated risks. Health care providers and systems should provide accurate information, early screening and treatment, and recommend appropriate behavioral modifications for individual South Asians at heightened risk.
At the community level, a multi-level, comprehensive education campaign—with high visibility at cultural events or venues—might be effective in dispelling many of the myths associated with culturally-specific tobacco use. In addition to educational materials, culturally-appropriate resources for cessation as well as provision of alternative mechanisms to facilitate the preservation of traditional and celebratory practices and expression of cultural identity should be incorporated in such an effort.
Culturally-specific tobacco products should be included in regulations governing the import and sale of tobacco, ensuring they adhere to taxation statues and warning label guidelines. Enforcement of tobacco licensing regulations on retailers selling culturally-specific products may also curtail access and availability to youth, which is currently both common and socially acceptable in these settings. As more population-level data becomes available, additional targets for intervention may become apparent to reduce consumption and ultimately, tobacco-related disparities among this large migrant community.
As with most qualitative research, findings are not generalizable to communities beyond the study population. The small group design involving lesser number of respondents per group may have precluded generation of larger themes through dialogue between more respondents. While the use of only one reviewer for much of the data analysis might also have been a limiting factor, the extensive collaborative approach employed at the onset of data analysis, coupled with a rigorous quality assurance protocol upon its completion, resulted in a high level of agreement pertaining to theme extraction, identification and classification of qualitative data, and credible relationships to the research question. In addition, eventual saturation of themes, with corroborating data, suggest that the small group design was effective in generating information which help elucidate the cultural contexts sought after in this research. Triangulation of focus group data with observational data also lends credence to the study findings.
The use of non-traditional tobacco items is a pressing public health concern globally and among migrant cultural groups. Despite the demonstrable health risks, little is known about the patterns and predictors of tobacco use among diverse minority populations outside of cigarettes and Western forms of smokeless tobacco. This study elucidates the unique spectrum of South Asian tobacco products used in the United States and, the social influences and cultural motivations for use. It also provides an essential starting point to develop relevant quantitative measures to evaluate prevalence and correlates of culturally-specific tobacco use among South Asians in the United States and other migration destinations. Understanding the contextual determinants of tobacco use among this community—and other understudied minority groups—will facilitate development of relevant quantitative measures for culturally-specific tobacco use and population-based estimates and correlates of all tobacco use, ultimately enabling the creation of appropriately targeted interventions. In order to reduce tobacco-related disparities among ethnically diverse populations, future studies need to ensure that socio-cultural contexts of tobacco use are critically examined and applied to program and policy creation.