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Exploring the cultural context of tobacco use: A transdisciplinary framework

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Exploring the cultural context of tobacco use: A transdisciplinary framework
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  Exploring the cultural context of tobacco use:A transdisciplinary framework [Received 18 November 2002; accepted 30 June 2003] Understanding culture is an essential key to reducing tobacco use. Conceptualizations of culture vary across scientificdisciplines and theoretical orientations. Because of the complexity of the causes and effects of tobacco use, no singlediscipline has sufficient capacity to undertake a comprehensive approach to studying culture and tobacco.Transdisciplinary research offers a means of bridging disciplinary perspectives. This paper reviews epidemiologicaldata on observed variation in smoking patterns across national groups, ethnicities and genders, and presents reasonsfor studying culture in tobacco control research. We discuss and contrast conceptualizations and specific definitionsof culture and identify aspects of each conceptualization that are relevant to research on tobacco. We present amultilevel, multidimensional conceptual framework for transdisciplinary research teams to use to think togetherabout the influence of culture on tobacco and of tobacco on culture. The framework challenges researchers to thinkabout how the sociocultural context influences tobacco use at micro, meso, and macro levels. Finally, we offersuggestions for improving transdisciplinary research on culture and tobacco. Tobacco control research, like most fields, has beenhampered by boundaries between scientific disciplines.In no case is this problem more evident than inresearch on culture and tobacco use. Fortunately, inrecent years, researchers from many scientific dis-ciplines have begun to come together to considerhow people’s culture shapes their tobacco-relatedattitudes, ideas, beliefs, and behaviors. The variationacross cultures and ethnic groups in the prevalenceand habits of tobacco use makes clear the importanceof understanding cultural influences on smoking.However, the approach to take to understandculture and tobacco use is far from clear. Scientificdisciplines vary in how they conceptualize andapply notions of culture to tobacco research. Adefinition or theory of culture that is useful in onediscipline might not be meaningful when appliedwithin another discipline. This article describes theneed for researchers from different scientific disci-plines and perspectives to cooperate to create a sharedlanguage and shared models about the role of culturein tobacco use. We identify conceptual issues thathave arisen through this endeavor, offer a basicframework to stimulate transdisciplinary thinkingabout culture and tobacco use, and identify directionsfor translating research into practice and action toreduce tobacco use. Why study the cultural context of tobacco use? Tobacco is used throughout the world, but cultureshapes the specific methods and patterns of its use.For example, in Cuba tobacco is smoked in hand-rolled cigars, whereas in India it is smoked in bidis Jennifer B. Unger, Ph.D., Tess Cruz, Ph.D., Lourdes Baezconde-Garbanati, Ph.D., Sohaila Shakib, Ph.D., Paula Palmer, Ph.D. andC. Anderson Johnson, Ph.D., University of Southern CaliforniaKeck School of Medicine; Alexandra Shields, Ph.D., GeorgetownUniversity Institute for Health Care Research and Policy; Jon Cruz,Ph.D., University of California, Santa Barbara; Jeremiah Mock,MSc, Ph.D., University of California, San Francisco; ElizabethEdsall, MSc. and Thomas Glynn, Ph.D., American Cancer Society;Ellen Gritz, Ph.D., University of Texas M. D. Anderson CancerCenter.Correspondence: Jennifer B. Unger, Ph.D., University of SouthernCalifornia Institute for Health Promotion and Disease PreventionResearch, 1000 S. Fremont, Box 8, Alhambra, CA 91803, USA. Tel: z 1 (626) 457-4052; Fax:  z 1 (626) 457-4012; E-mail: unger@usc.edu Jennifer B. Unger, Tess Cruz, Sohaila Shakib, Jeremiah Mock,Alexandra Shields, Lourdes Baezconde-Garbanati, Paula Palmer, Jon D. Cruz,Elizabeth W. Edsall, Ellen R. Gritz, Thomas Glynn, C. Anderson Johnson Nicotine & Tobacco Research  Volume 5, Supplement 1 (December 2003) S101–S117 ISSN 1462-2203 print/ISSN 1469-994X online  #  2003 Society for Research on Nicotine and Tobacco DOI: 10.1080/14622200310001625546   (small flavored cigarettes), and in Indonesia it isblended with clove. Smokers in Syria smoke tobaccotogether in a narghile (large standing water pipe),whereas smokers in Southeast Asia smoke it in a suipa(clay pipe) individually. Beyond smoking, tobaccoalso is inhaled through the nose as snuff and ingestedorally as chewing tobacco and betel quids (Mackay &Eriksen, 2002).Smoking prevalence varies substantially acrossnations, ethnic groups, genders, and other demogra-phically defined groups (U.S. Department of Healthand Human Services, 1998). A comparison of smokingprevalence rates across national populations andacross ethnic groups in the United States reveals theextent of this variation (Centers for Disease Controland Prevention, 2002; Corrao, Guindon, Sharma, &Shokoohi, 2000). Figure1 shows that among some of the world’s most populous nations, the prevalence of current smoking varies from 17% to 64% among adultmen and from 1% to 42% among women (Corraoet al., 2000).Smoking prevalence rates vary substantiallybetween the genders in some nations but not in others.In China, there is a large gender discrepancy insmoking (63% of men and 4% of women), whereas inBrazil the discrepancy is much smaller (38% of menand 29% of women). Among Native Americans in theUnited States, the prevalence of smoking is higheramong women (43%) than among men (29%). Giventhat there is no known genetic or biological basis forthe variation in gender patterns of smoking acrosspopulations, we are left only with environmentalconditions as possible causes. If one interpretsnational and ethnic groups as cultural groups—anapproach that has limitations discussed below—thesedata suggest that the gender ideologies within thesecultural groups likely have an important influence onsmoking prevalence patterns across genders. Withinevery society, gender ideology and gender roles aredeeply rooted in culture. Therefore, the influence of culture on gender patterns of tobacco use becomes aprime focus for investigation.The approaches that researchers take to examinethe influence of culture on gender differences in Figure 1.  Sources: Centers for Disease Control and Prevention (2002); Corrao, Guindon, Sharma, & Shokoohi (2000).Note. U.S. data are from 2000; data from other countries are the most recent data available, ranging from 1996to 2000. S102  EXPLORING THE CULTURAL CONTEXT OF TOBACCO USE  tobacco use are influenced by the researchers’disciplinary or theoretical orientations. Some research-ers view gender-related smoking prevalence patternsas a target for public health interventions (U.S.Department of Health and Human Services, 2001),as a product of industrialization or Westernization(Hippert, 2002), as an expression of women’s relativeequality and power in society (West & Zimmerman,1987; Connell, 1987; Lorber, 1994), as a response tochanging body image ideals (Amos, Gray, Currie, &Elton, 1997; Voorhees, Schreiber, Schumann, Biro, &Crawford, 2002), or as an outcome of targetedmarketing strategies (Amos & Haglund, 2000). Acomplete explanation is likely to include multipleinterpretations.The description above, while instructive, containsone important flaw: It uses race, ethnicity, andnational srcin as proxy measures of culture. In theUnited States, most research on variations in tobaccouse has used bureaucratic categories of race, ethnicity,or national srcin to delineate cultural groups (e.g.,Centers for Disease Control and Prevention, 2000,2001, 2002; U.S. Department of Health and HumanServices, 1994, 1998). However, because race is asocially constructed category rather than a biologicalcategory, these categorizations are not meaningfulwhen applied to biologically based scientific disciplinessuch as genetics. In many health studies, racial orethnic variables are used as proxy measures of culturalgroups under the assumption that racial or ethnicgroups share cultural practices, belief systems, andcustoms (Chin & Humikowski, 2002; Murry, Smith, &Hill, 2001). When applied to biological research ontobacco use, the assumption is often made that self-identified racial or ethnic categories are indicators of groups that share similar genetic makeup and/or areexposed to similar environments. Self-identified racialor ethnic categories actually might be proxies for theimpact of institutional structures, policy decisions, orlocalized environmental factors such as poor access tohealth care, fewer educational or employment oppor-tunities, or proximity to environmental toxins (Senior& Bhopal, 1994; Williams, Lavizzo-Mourey, &Warren, 1994). In addition, because race and ethnicityare social constructs rather than biological categories,definitions of race and ethnicity differ across culturalcontexts (Okazaki & Sue, 1995). In conductingtransdisciplinary research on culture and tobacco, itis important to match the operationalization of constructs with the goals of the research.Within broad groups, whether racial, ethnic, ornational, substantial variation in tobacco use can beattributed to other demographic factors, such asgender, socioeconomic status, age, and migrationhistory (Perez-Stable et al., 2001). It is incorrect toassume that all people who share a common racialidentity, ethnic identity, or nation of ancestry will alsoshare values or health beliefs. Moreover, it is incorrectto assume that people who share the same nation of ancestry share the same culture. Individuals vary inthe degree to which they identify with, and followthe norms of, the cultures with which they interact.Many individuals identify with some aspects of oneculture and some aspects of other cultures (Berry,1980, 1998; Marin, 1996; Marin, Perez-Stable, Marin,& Hauck, 1994; Cuellar, Arnold, & Maldonado, 1995;LaFramboise, Coleman, & Gerton, 1998; Oetting &Beauvais, 1991; Padilla, 1980; Phinney, 1998; Phinney& Devich-Navarro, 1997). When people move to anew cultural context or interact with others fromdifferent cultural contexts, they might alter their notionsof leisure, style of speech, social behavior, attitudes,beliefs, and customs, including those relevant to tobaccouse. Multicultural attitudes and behaviors also candevelop when aspects of one culture are exported toanother culture through the print or electronic media.Movies, television programs, music, books, and comp-uter games can convey cultural norms and beliefs,including those relevant to tobacco, to people nearlyanywhere in the world. However, within any culturalgroup there will be a great deal of variation in howpeople interpret the information they receive.Clearly, tobacco control research needs a morecareful approach to understanding the role of culturein shaping smoking patterns. The variation in overallprevalence of tobacco use and in gender patterns of tobacco use suggests that culture plays an importantrole in influencing tobacco use, along with socio-economic, psychosocial, and biological factors. Thevariation across nations and ethnic groups in theprevalence and habits of tobacco use makes clearthe importance of understanding cultural influenceson smoking. However, the approach to take tounderstand culture and tobacco use is far fromclear. Conceptualizing the influence of culture ontobacco has proven to be a difficult task for any singlescientific discipline to undertake. Why take a transdisciplinary approach to researchon culture and tobacco? Research on tobacco control lacks a commonlanguage through which to communicate aboutculture. Researchers from different disciplines whostudy tobacco control use the terms  culture ,  cultural beliefs , or  cultural values . In tobacco control research,these terms are often used without precision and areoften used interchangeably without adequate consid-eration of their significance and distinctions. More-over, because researchers conceptualize culturedifferently and often work in disciplinary isolation,the same terms have different meanings and implica-tions across disciplines. From some perspectives,culture is something in a person’s immediate existenceto be measured as one of many risk or protective NICOTINE & TOBACCO RESEARCH  S103  factors for smoking. For example, in genetic epide-miology, social psychology, and other disciplines thatuse the deductive approach from the natural sciences(i.e., hypothesis testing with experimental or quasi-experimental designs), researchers typically frameculture as a variable to be measured and included ina causal model. From other perspectives, culture issomething all-encompassing that permeates everyaspect and level of human existence. In anthropology,and in some approaches in sociology that use theinductive approach (i.e. hypothesis generation throughmultiple iterations of investigation), researchers typi-cally conceptualize culture as the context in which allhabits occur and take a holistic approach to under-standing people’s ideas and practices.These varying approaches to culture, both in con-ceptualization and in measurement strategy, create agap in understanding across disciplinary boundaries.Because researchers from different disciplines areusing different assumptions about the practice of science, they frequently have difficulty communicatingabout cultural issues that are studied by multipledisciplines.Transdisciplinary research seeks to bridge tradi-tional boundaries between scientific disciplines, bring-ing together experts from multiple fields to create newconceptual models and paradigms to address acommon problem (Klein, 1996). Rosenfield (1992)distinguishes transdisciplinary research from multi-disciplinary and interdisciplinary research. In  multi-disciplinary  research, researchers in various fields workindependently or sequentially to address aspects of aresearch question that are relevant to their specificfields of expertise, without integrating the resultsacross disciplines. In  interdisciplinary  research, resear-chers from two or more disciplines work together on aparticular problem, with each researcher using theo-retical models and methods from his or her area of expertise. Although the researchers are collaboratingto solve a problem, each researcher is addressing adifferent part of the problem.In  transdisciplinary  research, researchers work jointly from a shared conceptual framework thatdraws together discipline-specific theories, concepts,and approaches to address a particular problem. Thecollaboration of researchers from diverse fields facil-itates the examination of a problem from multiplelevels of investigation. Because many factors influencetobacco use, transdisciplinary research is particularlywell suited to achieve a more comprehensive under-standing of culture in the study of tobacco use, whilealso offering unique opportunities for the translationof that research into practice.Because universities and research institutes typicallyare organized into isolated, discipline-specific depart-ments, mechanisms and incentives are necessary toencourage researchers from various disciplines to meetone another and create transdisciplinary researchstrategies (Klein, 1996). One way to create incentivesfor transdisciplinary research is to allocate fundingto transdisciplinary research groups. In 1999, theNational Cancer Institute and the National Instituteon Drug Abuse funded seven TransdisciplinaryTobacco Use Research Centers (TTURCs). Althougheach TTURC has a unique research focus, manyof the TTURC research projects address issues of culture and tobacco use. The following sectiondescribes some conceptual issues that arise intransdisciplinary research on tobacco and presentssome ways in which research on culture and tobaccocould be integrated across disciplines. When applic-able, examples of research conducted by the TTURCsare presented. Conceptual issues in transdisciplinary research onculture and tobacco Can researchers from different disciplinary perspec-tives agree on a useful definition of culture? A centralfeature of transdisciplinary research is the develop-ment of shared conceptual models that integratediscipline-specific theories, concepts, assumptions,and approaches to improve the understanding of anissue (Rosenfield, 1992). However, because of thecomplexity of habits such as tobacco use, no singleconceptualization or definition of culture will bemeaningful for all research on culture and tobacco,especially across disciplines. A transdisciplinary teamof researchers can, instead, suggest which aspects of specific conceptualizations and definitions of cultureare germane to the task of studying culture andtobacco use, thereby creating a mutual understanding.In the following section, we present several importantconceptualizations and definitions of culture thatcould be applicable to the study of tobacco.Undoubtedly, there are others that may be useful.Thus, we present the discussion below as a summaryof important considerations that have arisen duringthe debates about the culture concept, rather than asan exhaustive treatment.Culture has been defined from many disciplinaryperspectives, ranging from sociocultural anthropology(e.g., Kroeber & Kluckhohn, 1952) to evolutionarybiology (e.g., Dawkins, 1976). Although culture hasbeen a central focus of the social sciences, more than acentury of vigorous debate has expanded the conceptof culture, yielding new permutations rather than asingle grand theory of culture. Scholars in anthropo-logy and sociology have proposed overarchingtheories of culture (e.g., Tylor, 1871; Durkheim,1926; Benedict, 1934; Levi-Strauss, 1963). Tylor’sconceptualization of culture as ‘‘that complex wholewhich includes knowledge, belief, art, morals, law,custom, and any other capabilities and habits acquiredby man as a member of society’’ is a good starting S104  EXPLORING THE CULTURAL CONTEXT OF TOBACCO USE  point for research on tobacco by specifying thebreadth across which culture spans. The search fora unifying theory of culture gained popularity amonglogical positivists in the mid-twentieth century (Ayer,1959; Cohen & Nagel, 1934; Kroeber & Kluckhohn,1952). For example, Kroeber and Kluckhohnattempted to synthesize the many definitions of culture into a grand theory, stating that culturecomprised everything that humans thought, felt,imagined, or created that was not directly attributableto a biologically rooted impulse. Such an expansivedefinition of culture is difficult to operationalize inresearch on tobacco use, because it subsumes nearlyall nonbiological phenomena related to tobacco.As consensus about the culture concept becamemore elusive, social scientists abandoned the quest fora grand theory in favor of the study of culture in localpeople’s context-bound, socially and historicallyshaped ideas, feelings, and habits. The shift from aunifying theory toward grounded case studies doesnot indicate a lessened interest in, or importance of,culture, but rather a different strategy for studying it.The culture concept was not abandoned; instead, itwas redefined continuously within disciplines suchas anthropology, sociology, social psychology, andpublic health, according to their particular disciplinaryobjectives. Today, even within specific disciplines, onecan find substantial variations in the conceptualiza-tion, uses, and application of the culture concept.For the purposes of thinking about tobacco’sfunctional, normative, and symbolic place in societies,cultures can be seen to ‘‘comprise systems of sharedideas, systems of concepts and rules and meaningsthat underlie and are expressed in the ways thathumans live’’ (Keesing, 1985). One anthropologicalperspective (Goodenough, 1961, 1963) might focus onunderstanding how social norms about tobacco useare culturally constructed, how a society determineswhere and when it is appropriate to use tobacco, howa particular society negotiates what should or shouldnot be changed about tobacco use, and how somepeople mobilize to control tobacco use while othersresist tobacco control measures. This process-orientedconceptualization of culture offers one pathway foroperationalizing the study of culture in tobaccocontrol research.Geertz (1973) advocated analyzing and interpretingsymbols, particularly symbols of language, to under-stand the processes that generate and regeneratecultural knowledge. This holistic approach to cultureseeks to reveal the underlying symbolic cultural logicthat guides most human behavior, and is simulta-neously the human behavior. People make meaningout of cultural objects such as tobacco within highlysymbolic, ritualized activities. Using this conceptuali-zation of culture, one might view the concept of thesmoker as inseparable from the concept of smoking,as the dancer can be viewed as inseparable from thedance.In contrast to Geertz, Triandis approached culturefrom a social psychology perspective, dividing cultureinto ‘‘material’’ and ‘‘subjective’’ culture (Triandis,1972). Material culture constitutes things made byhumans (e.g., cigarettes and cigars) and subjectiveculture constitutes ways a society perceives of its socialenvironment (e.g., perceptions about which groups of people typically chew tobacco). Triandis’s approach tothe study of culture is literal and behaviorallyoriented. Triandis recommended that an investigatorfocus on subdividing subjective culture into specificelements, such as categories, associations betweencategories, beliefs, attitudes, norms, roles, and values.This approach lends itself to studying the constituentcomponents of culture rather than framing it as ‘‘acomplex whole.’’Although scientific disciplines do not share a singledefinition of culture, many disciplines share the notionthat cultural elements shape the behavior of indivi-duals, groups, and societies. Rather than try to imposea grand theory of culture on researchers working in atransdisciplinary effort, the approach in this article isto illustrate some potential opportunities to broadenour understanding of the role of culture in tobacco useby examining it from multiple perspectives, to indicateways in which the study of culture might be furtheroperationalized, and to suggest how scientific dis-coveries might be translated from scientific discoveryinto practical application. This approach generatesmore questions than answers, indicating the magni-tude of this challenge as well as the potentialadvancement of knowledge that could result fromattempting to address the challenge. A transdisciplinary framework for studying culturalinfluences on tobacco use Transdisciplinary research strives to develop sharedconceptual models that integrate discipline-specifictheories, concepts, assumptions, and approaches toimprove the understanding of an issue (Rosenfield,1992). No single, overarching definition or conceptua-lization of culture is adequate or meaningful for allresearchers because each approaches tobacco controlresearch from a different perspective.Traditionally, most researchers interested in pre-venting tobacco use or facilitating tobacco cessationhave concentrated on studying tobacco use andnicotine dependence at a single level of investigation.Examining the influence of culture on tobacco use at asingle level can be informative, but to produce a morecomplete picture of the total cultural context in whichtobacco use occurs, we propose a framework thatchallenges researchers to explore multiple contextual NICOTINE & TOBACCO RESEARCH  S105
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