Journal of Community Health

, Volume 42, Issue 3, pp 544–550 | Cite as

Smokeless Tobacco Decision-Making Among Rural Adolescent Males in California

  • Elizabeth T. Couch
  • Ellen Darius
  • Margaret M. Walsh
  • Benjamin W. Chaffee
Original Paper


Smokeless tobacco (ST) use among US high school males living in rural areas exceeds national levels. Subgroups at heightened risk of ST use have been identified, but less is known regarding ST decision-making within high-risk groups. The study objective was to describe rural adolescent males’ perceived ST acceptability, health risks, and social implications and how those perceptions differ between ST users and never-users. Semi-structured individual interviews were conducted with a purposeful sample of 55 male students (32 ST ever-users) at three rural California high schools. Interviews were audio recorded and professionally transcribed. Investigators collaboratively developed a codebook based on thematic content and then independently coded transcripts, reconvening frequently to achieve consensus. Coded text was systematically organized into themes following a general inductive approach. ST users and non-users shared multiple ST-related perceptions, including: that ST is a common, normative way of life in rural “country” culture among certain groups; that ST use conveys oral health risks; and that the decision to use (or not to use) is rooted in personal choice. ST users’ and never-users’ perceptions differed regarding the immediacy, severity, and inevitability of health risks, particularly relative to cigarette smoking. Other differences included perceived parental permissiveness and the expected social benefits of ST use, such as peer acceptance and conveying maturity. Within this population of rural male adolescents, ST users emphasized the social benefits of ST use, while acknowledging but discounting health risks. Differences and similarities in tobacco perceptions among adolescents living in similar environments may inform effective health communication.


Smokeless tobacco Adolescents Rural health Health behaviors Risk perceptions 



Thank you to Joanna Hill, Archnaa Rajasekaran, and Janelle Urata, all of the University of California San Francisco, for administrative and technical support. The authors would also like to acknowledge Bonnie Halpern-Felsher, of Stanford University, and Maria Roditis and Janine Cataldo, of the University of California San Francisco, in the development of the interview guide. The authors acknowledge the passing Dr. Margaret Walsh, whose exceptional leadership and scholarship over 37 years at the University of California will have a lasting impact in the field of tobacco control.


This work was supported by the US National Institutes of Health, National Cancer Institute and Food and Drug Administration Center for Tobacco Products [Grant No. P50CA180890] and the NIH National Center for Advancing Translational Sciences [Grant No. KL2TR000143]. The content is solely the responsibility of the authors and does not necessarily represent the views of the NIH or FDA. The authors affirm that there are no conflicts of interest related to the publication of this work.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.


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Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Elizabeth T. Couch
    • 1
  • Ellen Darius
    • 1
    • 2
  • Margaret M. Walsh
    • 1
  • Benjamin W. Chaffee
    • 1
  1. 1.Department of Preventive and Restorative Dental SciencesUniversity of California San FranciscoSan FranciscoUSA
  2. 2.Division of Epidemiology, School of Public HealthUniversity of California BerkeleyBerkeleyUSA

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