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The California Adolescent Health Collaborative, a project of the Public Health Institute, in partnership with the University of California, San Francisco’s Center for Tobacco Control Research and Education jointly led a community-based participatory research (CBPR) study engaging youth coresearchers to fill the critical gap in knowledge about youth’s perceptions of electronic cigarette products and how they are marketed toward young people in Oakland. Youth coresearchers who were trained as journalists partnered with the adult investigators to explore the e-cigarette topic from their perspective, embedded in the context of their own experiences and those of others in their communities. The goal of this exploratory CBPR study was to improve understanding of how and why youth (ages: 14-24 years) in Oakland are adopting (or resisting) e-cigarettes, how youth respond to increasing availability of e-cigarettes in their communities, and how they perceive communications about e-cigarettes (e.g., advertising) and in turn communicate about the products to each other. Keywords Community-based participatory research, youth participatory action research, tobacco, e-cigarettes methodologies, photovoice, and geo-narratives. This article Introduction describes the background and significance of our research The marketing of e-cigarettes toward adolescent in Oakland topic, details the process and methodologies of this intergen- (META-Oak) study was a community-based participatory erational CBPR study, including how we disseminated our research (CBPR) project that aimed to answer the following findings, and outlines the results. We incorporate lessons question: How are electronic nicotine delivery systems learned and challenges, discuss implications of our findings, (e-cigarettes) marketed to young people in Oakland, and how and recommendations for practice, policy, and future do youth perceive e-cigarettes? Young journalists were research. This article was coauthored by the study’s coprinci- recruited from a youth media organization to participate in pal investigators (Co-PIs; A.C. and P.L.), the youth core- training on research, tobacco marketing trends and tactics, searchers (E.M. and N.P.) and an adult ally coresearcher and and the health impacts of e-cigarettes and other alternative program manager (R.E.L.): Throughout the article, we refer tobacco products. Twelve young journalists participated in initial training sessions; when the youth media organization left the partnership (see “Discussion” section for more details Public Health Institute, Oakland, CA, USA on this transition), five youth chose to continue to partici- California Youth Advocacy Network, Oakland, CA, USA pate, joining the project leadership team as youth coresearch- Kent State University, OH, USA ers. These five youths contributed to the research question, University of California, San Francisco, CA, USA design, and data collection, but two of them moved on to Corresponding Author: college or work before they could engage in data analysis Alison Chopel, Public Health Institute, 555 12th Street, 10th Floor, and dissemination of findings. They collected and analyzed Oakland, CA 94607, USA. Email: A.M. Chopel@gmail.com data from their communities using multimedia participatory Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http://www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open to our core team in the tradition of reflexive analysis (Finlay such as little cigars and cigarillos, smokeless tobacco, and & Gough, 2003). e-cigarettes (Waxman, 2009). Thus, there is an urgent need to understand youth expo- sure to e-cigarette advertising and their perceptions of adver- Background tising messages. In addition, it is important to gain a better Smoking is the leading preventable cause of death in the understanding of the exposure to flavored tobacco products, United States, and if smoking continues at current rates, 5.6 and the impact of flavored tobacco products on youth per- million young people below the age of 18 years will die of a ceptions of tobacco and use of these products. For increased smoking-related disease (U.S. Department of Health and understanding of both these issues, it is vitally important to Human Services, 2014). Youth smoking prevention is impor- have local data on the availability of tobacco products, expo- tant, as 90% of all people who start smoking do so before the sure to advertising, and a youth perspective on this advertis- age of 18 years, and 99% start by the age of 26 years (U.S. ing. These data and improved understanding will enable Department of Health and Human Services, 2012). Although development of educational programs for youth and the cre- youth smoking has declined over the past decade, use of non- ation and passage of public policies responsive to the rapidly cigarette tobacco products has increased. The most rapid changing environment and product landscape. This study increase has been in the use of e-cigarettes, which are bat- sets out to fill this need while developing a unique partner- tery-powered devices that heat a solution to produce an aero- ship between academic and community health researchers sol typically containing nicotine, flavorings, and other and youth in Oakland. additives to be inhaled by the user (U.S. Department of Health and Human Services, 2012). Between 2011 and 2015 Context there was a dramatic increase in e-cigarette use among youth and young adults, and e-cigarettes are now the most com- Diversity and gentrification. Oakland is the eighth largest city in monly used tobacco product among youth (U.S. Department California, with a population of over 4,00,000 in 2015, and it of Health and Human Services, 2016). Youth who use e-cig- was ranked as the most racial/ethnically diverse city in the arettes are also 3 times more likely to go on to combustible United States in a 2017 study (Bernardo, 2017). The racial/ cigarette smoking in the future (Primack, Soneji, Stoolmiller, ethnic mix of the city is 38.7% White, 30.5% Black or Afri- Fine, & Sargent, 2015; Wills et al., 2017). can American, 18.9% Asian or Asian American, 2.1% Amer- E-cigarette devices are very diverse, with considerable ican Indian/Alaska Native, 0.9% Native Hawaiian/Pacific variations in appearance and nicotine delivery ranging from Islander, 15.3% Other, and 25.4% Hispanic or Latino (City of “cigalikes” (devices that appear like cigarettes) to “vape Oakland, n.d.). Within this context of racial/ethnic diversity, pens” or elaborate “mods” that can be built and customized rising rent and housing prices have contributed to gentrifica- by the user (Zhu et al., 2014). These devices are used for a tion and displacement throughout the San Francisco Bay wide variety of reasons, and these reasons can evolve over Area, with more families migrating out of Oakland to sur- time (Hoek, Thrul, & Ling, 2017). In addition, e-cigarette rounding suburbs such as Antioch, Pittsburg, and Union City advertising is increasing, including in magazines and on tele- (Allen-Price, 2017). Moving to the suburbs may also impact vision (Kim, Arnold, & Makarenko, 2014), and receptivity to tobacco use. One of our youth coresearchers (N.P.) lived in a e-cigarette advertising among youth is associated with geographically distant suburb and noted that, among youth, greater susceptibility for cigarette smoking of all types smoking cigarillos and flavored tobacco was not as prevalent (Pierce et al., 2017). as it was in Oakland. The tobacco products used more fre- Another important factor influencing youth smoking is quently in the suburban area seemed to be e-cigarettes and the presence of flavored tobacco products. E-cigarettes are vape pens, as well as hookahs (Governing, n.d.). available in over 7,000 flavors, including flavors with youth appeal such as fruit flavors (e.g., strawberry, grape, cherry, Community setting and policy context. Oakland has a long his- blueberry), candy flavors (cotton candy, vanilla, chocolate, tory of organizing, with many grassroots organizations and bubble gum), dessert and snack flavors (banana cream pie, youth development centers. Many youth-serving organiza- froot loops, cheesecake, donuts, cookies and cream), and tions and some high schools are located in Downtown Oak- popular savory food flavors (chicken and waffles, pizza, land (Youth Radio, Girl’s Inc, Envision Academy of Arts & bacon; Zhu et al., 2014). Most youth tobacco users start with Technology, Oakland School for the Arts, SMAAC Youth a flavored product, including the majority of cigarette smok- Center, YMCA, among others), which made it a logical place ers, e-cigarette users, and cigar users (Ambrose et al., 2015). to focus the study (Figure 1). In addition, the tobacco policy Although the 2009 Family Smoking Prevention and Tobacco environment in California as well as the San Francisco Bay Control Act prohibited the sale of cigarettes with character- Area is rapidly changing. In 2016, the FDA deeming rules izing flavors, this regulation did not include menthol ciga- came into effect, exerting regulatory authority over e-ciga- rettes, and it did not include noncigarette tobacco products rettes for the first time (Department of Health and Human Chopel et al. 3 Figure 1. Study boundaries map. Services & Food and Drug Administration [FDA], 2014). keep people in their place within societal hierarchy, and that Following the deeming rule, California passed its most an important step in combating this ongoing assault on free- expansive legislative package on tobacco in decades, includ- dom is conscientization. Conscientization is the process ing raising the age of purchase to 21 years, including e-ciga- whereby colearners gain critical consciousness, or an aware- rettes in the definition of tobacco products, establishing ness of the ways that meanings are constructed and main- licensing for tobacco products, and closing loopholes in tained in their world to support oppression (such as coercive smoke-free policies (The Editorial Board, 2016). California and targeted advertising that undermines the health of vul- voters also passed the Proposition 56 ballot measure, estab- nerable populations, including youth of color), the ways they lishing a new US$2 tax on tobacco products in 2016. In June are “objects” of others’ will and can instead become a “sub- 2017, San Francisco passed the first comprehensive ban on ject” of their own will (Paiva, 2000). Subjects are empow- the sale of menthol and flavored tobacco products within the ered to change their environment and circumstances in the city, and similar legislation was adopted in Oakland soon process of a listen-dialogue-action cycle (Minkler & after. Within this context, findings from this study were able Wallerstein, 2011). to contribute to further advocacy efforts to limit youth access Empowerment theory informs many aspects of the prac- to tobacco and e-cigarette products. tice of CBPR, our research orientation, including the impor- tance of coresearchers coming from the communities of interest and the necessity of including an action component Theoretical Framework as part of the investigation process. A research team of Empowerment theory is derived from Freirean pedagogical Oakland-based youth and adult researchers met weekly to theory and posits that oppression works on many levels to make decisions, design processes and instruments, build 4 SAGE Open team cohesion and conduct the business of the project, youth health and antitobacco advocacy. The steering com- including developing and delivering training and collecting mittee met every other month throughout the duration of the and analyzing data, and disseminating findings. In our project, to participate in guiding decisions around the research team, the two (adult) Co-PIs and other adults on the research question and methodology, and to participate in steering committee positioned themselves as adult allies to training and analysis, as well as supporting communication their youth colleagues. This meant building the skills and of findings and keeping the team abreast of developments in knowledge of youth leaders enabling them to make meaning- research and policy, a task especially essential while investi- ful decisions about the research and then connecting them to gating such a new and fast-moving subject as e-cigarettes. resources to carry out those decisions. Resources included content and methods training, creating a meeting and super- Method visory structure, food, space, equipment, and compensation via wages. Rather than having youth make all the decisions CBPR is practiced on a continuum, from more community- on their own, youth were a valued part of the decision-mak- generated to more academic-led. The team attempted to main- ing team. tain a balance near the center of the continuum, so while the health issue to be studied was decided upon when the funding proposal was written, the youth participants and steering com- Method mittee collaboratively refined the specific research question. First, multiple trainings on content knowledge were con- Study Design ducted, including on the history of tobacco consumption and Organizational partners. Three organizations, which focused sales, the state-of-the-art knowledge on e-cigarette health on youth empowerment and public health, came together to impacts, targeted marketing tactics of tobacco companies from create this study. The California Adolescent Health Collab- the 1950s until the present, and the “triangulum” of tobacco, orative (CAHC), a program of the Public Health Institute, e-cigarettes, and marijuana. Armed with this knowledge, seeks to center youth as researchers to understand and through a multistep process of brainstorming and pile-sorting address issues of health equity impacting adolescents. The ideas, various aspects of the larger issue of e-cigarettes and Center for Tobacco Control, Research and Education adolescents were prioritized, and refined until the following (CTCRE), of the University of California, San Francisco, is research questions were reached by consensus: a nexus for academic tobacco research, including active studies identifying marketing trends, patterns of use, and Research Question 1: How are e-cigarettes marketed and health effects of electronic nicotine delivery systems. Youth promoted to youth in Oakland? Radio, a media-training organization, builds capacity of Research Question 2: How are these products perceived youth in journalism and had recently produced a video on the by youth in Oakland? burgeoning use of electronic cigarettes by young people in Oakland (Bolario, 2013). These three organizations devel- Based on the questions, the team determined qualitative/ oped and launched the study collaboratively. exploratory methods would be most efficacious in answering the “how” questions. The group participated in training on Study orientation. The study was designed as a CBPR study, research basics and the difference between qualitative and where the community was defined as young people ages 14 quantitative methods, research ethics, various research meth- to 24 years living, working, or studying in Oakland, and ods (including in-depth interviews, focus groups, photo- those who work with or for them. CBPR is action-oriented, voice, and geo-narratives) and how to determine appropriate equitable, and serves as both an intervention and an investi- methodology to align with research questions. The core gation. It is ideal for marginalized and vulnerable popula- research team, consisting of three to five enthusiastic and tions such as adolescents, because by engaging members of committed youth (two youth researchers left the team before the focus population as coresearchers, the “relevance, rigor the conclusion of the study in order to attend college) and and reach” (Morello-Frosch, Pastor, Sadd, Porras, & Prich- three adult allies including the Co-PIs, then determined that ard, 2005) of the research is improved and simultaneously photovoice was the best fit for research questions and skills the young people gain access to power and have voice in of the co-researchers. The youth researchers collected 39 arenas where they are traditionally not present (including, in photos with narratives using photovoice. Later, there was an this case, academic research and policy advocacy). opportunity to pilot-test collecting geo-narratives (a novel A key resource for this study was the steering committee, form of data collection new to all on the team), to comple- comprised of representatives from public organizations (the ment photovoice, which resulted in two narrated videos with Alameda County Public Health Department, the National maps. Although the team initially expressed interest in con- Cancer Institute) and nonprofit organizations (California ducting in-depth interviews, the richness of the data already Youth Advocates Network, American Lung Association, collected and limits on time and resources resulted in the Americans for Nonsmokers Rights, California School-Based determination that interviews would not be necessary. This Health Alliance) invested in tobacco-related disease research, allowed the team to have ample time to analyze the data in an Chopel et al. 5 iterative and participatory fashion. The research questions Analyses of the data were first conducted by the core were revisited periodically in context of our progress on data group involved in data collection, consisting of three youth collection and analysis, and it ultimately developed into researchers and three adult coresearcher/allies (the core “what are youth perceptions and responses toward the elec- research team). Two-step analysis included discussions of tronic cigarette and tobacco product marketing and messages the narratives, followed by systematic coding and develop- they encounter?” ment of themes across photos and narratives. As a group, we examined each photo and narrative, writing down the codes Photovoice. Photovoice is a well-known CBPR method that we saw in either the visual or written portion of the (Strack, Magill, & McDonagh, 2004) whereby participants piece. We then compared notes, and asked questions or made are given digital photography cameras and guided through a comments to come to agreement on the predominant codes, process to identify needs and assets in their communities combining similar codes and grouping subcodes under using photos and narratives. Photovoice draws upon empow- broader headings. We used sticky notes to visually manage erment theory, assuming that the people who suffer from a the process with many codes, and one person was assigned as problem are often the best equipped to address it in a way that the recorder, taking note of any discrepancies and document- is appropriate to their communities, but recognizing that they ing the process and decisions. In this way, the team collab- can face seemingly insurmountable barriers to action that oratively developed an initial codebook with all the codes stem from being in a disempowered state (Zimmerman, that emerged in the analysis process. Based on initial analy- 2000). The narrative analysis process that accompanies the ses, it was determined that saturation had been reached as collection of visual data by participatory researchers using the themes were being repeated in multiple photos and narra- photovoice technique supports the conscientization process. tives and no new themes were emerging, after 35 photos with Participants share their images and answer the following narratives had been collected and analyzed. We then reviewed questions about them (known by the acronym SHOWeD): the codebook as a team, discussing each theme in depth and “What do you See here? What is really Happening? How does looking back at supporting pieces of data. In this process, we this relate to Our lives? Why does this problem or strength also selected images and quotes that demonstrated each exist? What can we Do about it?” (Lee, Lipperman-Kreda, theme particularly well, and revisited the broader themes, Saephan, & Kirkpatrick, 2013; Wang, 2006) The photovoice finding it necessary to develop even broader “meta” themes training was a learning-by-doing training. We conducted one given that there were so many in our data. training where we introduced the basics, explored other pho- We then asked our steering committee members to “mem- tovoice projects, and discussed the theory supporting this ber-check” (Beebe, 2001) our analyses by assigning each method of data collection, then we met weekly as the youth member a group of photos and narratives belonging to a spe- researchers were engaged in data collection to troubleshoot cific meta theme. Steering committee members blind coded challenges and discuss their narratives. The youth researchers the groups of photos and identified what they felt were the took photos in their daily environments as well as sought out common themes. We asked them to answer a set of questions key sites where e-cigarettes are promoted in their communi- (see Figure 2) that either confirmed our thinking about the ties, and for each photo they took, they produced a narrative themes or revealed new questions. We found the perspectives by completing the reflective questions included in the of the steering committee members affirmed and reinforced SHOWeD acronym (as above). Prior to each week’s group session, the youth coresearchers chose at least one piece of visual and narrative data to share for analysis by the group. Data analysis. We engaged in a systematic coding of all of the data in an inductive-deductive analysis process; one that incorporates social phenomenological and grounded theory approaches (Fereday & Muir-Cochrane, 2006). The core research team integrated two coding processes: (a) system- atic inductive coding and (b) deductive analysis by the steer- ing committee to triangulate findings, in effect conducting coding comparisons between research team members and steering committee members located in different spaces with regard to adolescent perspectives on e-cigarettes and tobacco marketing. This process was ideal for this CBPR project as it utilized both the a priori theory that informed the design of the research and the everyday theories (Furnham, 1988) that all people, including all of the coresearchers and steering committee members, hold and may reveal in the data collec- Figure 2. Deductive analysis questions for steering committee tion/analysis/interpretation process. members to analyze Photovoice data. 6 SAGE Open the core group’s analyses and interpretations. We then con- providers, school officials, technology industries, local and nected and compared codes across data sources to identify state legislators and advocates, community organizations, overarching themes and relationships between emergent and other researchers via conference presentations, in-person concepts. This collaborative process reinforced co-owner- meetings with policy makers, an online video webinar, and a ship of the data and validated the expertise of the community community gallery event. researchers. It was important that the research findings be accessible to different stakeholders and not just the scientific and public Spatial video geo-narratives. Spatial video geo-narrative is a health communities. We presented our findings in various new technique whereby an individual is stimulated by his or forms of multimedia including a webinar, which is located her environment resulting in a primarily place-specific on Youtube (https://youtu.be/g3dsuwuxIwg) and on CAHC’s description. Unlike other geo-narrative applications, the webpage (www.californiateenhealth.org). We also used simultaneous video collection allows for an iterative induc- interactive technologies such as the Kahoots! game (an inter- tive-deductive investigation of the data. A subject describes active new generation app that enables participants to test his or her environment as a series of observations, memories, their topical knowledge by take quizzes via a mobile phone). and emotions, stimulated by passing sights, sounds, and The quiz is live and participants compete with each other in smells. The narrated content typically comprises of spatially the game to make it a fun way to educate youth on tobacco specific (an actual location is identified), spatially fuzzy (a awareness. general area that is known for activity), and spatially inspired (the conversation, or a sense that has been stimulated results Results in a more general insight). For example, Photovoice Codebook . . . it’s actually an elementary school down there, across the After the photovoice codebook was created and analyzed, street from my high school. And, a lot of kids come in here and the research team selected the most prominent themes based it’s like, they’re looking at it. And, it’s like, they probably think on both frequency of occurrence and importance by impact. it’s candy. So, like, you know, are you selling it to kids? It makes you wonder, like, are you selling it to kids? The tables below include the theme names, definitions, notes or points of significance, and a sample photo of each theme. This quote contains both spatially specific information, and The results are presented in two tables: meta themes (Table spatially inspired insight. After the narrative has been tran- 1, major themes) and other themes (Table 2, minor themes). scribed with media time stamps, Wordmapper software In these tables, we present some text either from the narra- allows the text to be merged with coordinates from the global tives that accompanied a photo related to the theme, or inter- positioning system path. Key words can be entered that will pretations of the data that emerged during analytic meetings generate word clouds (based on the comments containing the under the column marked “notes/significance,” and some key word) and maps, whereby every word, or beginning of a exemplar direct quotes matching the theme from the spatial comment, is located. Each key word or a comment contain- video geo-narratives in the final column. ing a key word is spatially identified. In this way, it is possi- ble to read the narrative for themes, explore those themes Colors and flavors. Two major themes that were identified through key words, identify cooccurring terms (to potentially repeatedly in the data are colors and flavors. Each of these modify the key word search), see where the themes map out, themes emerged repeatedly in the coding of the data, demon- and return to the video for additional visual insight. Previous strating both that a proliferation of colors and flavors does research has shown that this type of environment inspired attract the attention of young people and that the tobacco participation provides far deeper insights than in more typi- companies that own most e-cigarette companies also under- cal “indoor” questioning. Two youth coresearchers com- stand this fact and utilize it to their advantage. The variety of pleted spatial video geo-narrative interviews. For this article, different flavors documented by the photos also demon- an iterative process was used to identify themes in the narra- strates the proliferation of this tactic that tobacco and e-ciga- tive that reflected or complemented the themes that emerged rette companies are using to attract (and often addict) from the Photovoice data collection. adolescents. Furthermore, the youth coresearchers noted multiple times in their data the eye-level view at which these Dissemination of findings. The first set of audience that find- products are often displayed, that of a young child, and won- ings were presented to was to be the members of the steering dered whether that was part of an intentional “early indoctri- committee. The steering committee then assisted in identify- nation” strategy to saturate the reality of younger children ing venues for dissemination that would allow us to reach who visit these neighborhood stores with images that nor- both wide audiences and those with the ability to act on find- malize these products starting at a very early age. Similarly, ings to make an impact. We communicated our findings to the youth researchers, some of whom were caregivers for several audiences with different needs for research products their younger siblings, noted that many of these products including youth, youth-serving organizations and health care were almost indistinguishable from toys in their appearance 7 Table 1. Major Theme Occurrences in Photovoice Data. Notes from photo narratives/significance Sample photo with part of Theme name Definition expressed in analytic meetings accompanying narrative Example quote from geo-narrative Color and Images of the colors and flavors of tobacco Both colors and flavors increase appeal to “Swisher Sweets, they have a lot of the Newports flavor products or colorful displays of tobacco young audiences. and the Camels next to it. Back—like, that, and products (or e-juice), or colorful packages, The increasing variety and creativity of the then like it’s right next to the candy, where like, including colorful advertisements. flavors and colors are a way to target you see like, a lot of the fruity candy that has like, Colorful packages or advertisements appeal to specific groups of young people—kids the colorful wrappers as well.” young people because of enticing appearance, are more interested in a large variety of “And, it used to be very irritating, because I used or appearing to be like other youth- flavors and colors. to like the e—cigarettes, because it taste—it oriented colorful products. Especially things such as pizza, donuts, smells—Oh, it just—it smells sweet. It just like— Flavored tobacco products or advertising caramel apples, tropical blends, tastes like—I can’t even say it—tastes, because I for flavored e-juice, including fruit, candy, strawberry, blueberry muffin, cherry, didn’t taste it—but it smells like, you know, you or menthol. cherry cola, mango, watermelon, want to—like you—know—I don’t know, it’s “This problem is bigger than people (Color can be used to communicate a flavor cotton candy, peanut butter cups, like a funny way of my body where you can smell after the flavor descriptor is banned.) pineapple, cinnamon bun, dulce de may think. Look at how the colors something and then you could really taste it, how are the only thing that catches your leche, honey, cappuccino, espresso. it tastes. . ..” eyes and how it looks.” Inventory These photos depict large inventories in The idea that having a large inventory (No quotes from Geo-narratives that directly small stores. shows that the store’s priority is making pertain to this theme.) a profit, not educating, or providing a benefit to the community. Large inventory also gives the feeling that these products are normal or that using them is OK. “Over 200 flavors of chemical vapor juices” Product Pictures demonstrating strategic Kid’s eye view and product placement really “I go in there a lot and just like the other one, placement placement of tobacco and e-cigarette stood out to us because it all looks like where we first came out, he has like, candy, and products, including near other nontobacco candy, its color organized and flavors that the stuff in the back. So, in order for you to get products, presumably to increase sales by you can only dream of attracting child- candy, you have to look back there and then you having certain products near each other. teenage audiences. see all of the Swisher Sweet wrappers and stuff Products placed at a lower level, matching Product placement should be a like that, and then it’s like, why would you want with children’s eye view. legal issue. to put tobacco and candy next to each other? Like, do you want kids—and it’s—it’s actually an elementary school down there, across the street from my high school. And, a lot of kids come in “This relates to our lives because here and it’s like, they’re looking at it. And, it’s it’s promoting you to buy tobacco like, they probably think it’s candy. So, like, you product before you leave the store.” know, are you selling it to kids? It makes you wonder, like, are you selling it to kids?” (continued) 8 Table 1. (continued) Notes from photo narratives/significance Sample photo with part of Theme name Definition expressed in analytic meetings accompanying narrative Example quote from geo-narrative Advertising Pictures of advertisements for tobacco and This photo is basically showing video games “I think like, downtown is like, big marketing. Like, e-cigarette products, including advertising are the new way to communicate smoking you know, they’re going to have like a lot—a lot location, placement of advertising, packaging is cool and new for kids to do because it to like, put out there. More than up here. Because design, tobacco products that look like other is influencing it in child video games. down here, there’s like, where a lot of tours products because of the color, packaging, or come, a lot of people come, and they—you know, placement know a lot of people come down there, so they’re going to try and do it big. And, here it’s just like, oh, we’re going to give you like a poster here, a poster there, but like, and like, some of the—they be having like banners of it, and like, downtown.” “And, there’s always like people out here smoking and as you can see it’s like a lot of tobacco. Um, posters and stuff. There’s Backwood’s, Newport, “This relates to my life because my Marlboro, Camel cigarettes. Um, a lot of stuff. little brother who is 17 likes to play Alcohol, yeah. But, point is, they’re still advertising this game and my 2 year old brother a lot of cigarettes. . .The advertising is just as likes to watch.” much as West Oakland out here. So, it’s kind of funny how a lot of people out here are smoking e-cigarettes but there’s just as much tobacco, um, posters as West Oakland. So, I have yet to see a lot of people with like, swishers and stuff like that.” Marketing Photos showing selling points or messages in Tobacco companies are using new and “Yeah, my friend don’t like other cigarette brands, the advertising that make the tobacco product old marketing tactics to target. One because Newports—because she said they’re seem more attractive, including normalizing, example is the product line of Black Label smoother. But, I wouldn’t know. I know that I see creating the impression that more and more e-cigarette liquid. a lot of black people smoking Newports and I see people are using the product, labels such as like other races smoking like Camel or Marlboro. organic, local, all-natural, Black Label . .I really don’t know, maybe—maybe they are smoother than Newports and maybe the other kind have more Nicotine maybe. Who knows? I really don’t know . . . ” “The more fancy they look people want to get and try” 9 Table 2. Minor Theme Occurrences in Photovoice Data. Theme name Definition Notes/significance Sample photo Example quote from geo-narrative Trash and Photos of tobacco product trash and Trash can act like an advertisement due to “I just see like, a lot of—a lot of like—there’s a lot of litter nonbiodegradable wrappers thrown in the the prevalence of it on the street. You can people just like, smoking cigarettes. Then you see you like environment. see the colors or flavors on the packages a lot of cigarettes on the floor, on the ground. . . . Well, (they are large too). Selling singles or two people usually—you know, smoke, you know, outside. packs also generates more trash. They try to particularly stay away from the little kids, but it never works.” “This relates to our lives because they get seen every 200 footsteps and I feel like my lil siblings may get curious” Policy Photos depicting tobacco control policies, These 21+ law stickers are not really “Well, since they increased the law, they usually stand including limits or bans on advertising of effective in local neighborhoods because outside the liquor store and either—or they—not to tobacco products, including limits on colors, the tellers know the customers personally be mean, they ask them—a homeless person, to go in flavors, or buffer zones; age limits; includes and refuse to lose business even if they there and they give them money to go buy cigarettes no sales to minors, carding, telling adults not are below-age. This is a problem because and stuff.” to buy for minors; nonsmoking locations the flavored tobacco and e-cigarettes are “Um, I don’t know. I’m hoping that we were wondering, includes signs about no e-cigarette use or no targeted toward an adolescent audience. you’re under 18, they ID you. Because, it’s the law.” smokeless tobacco use. The video surveillance is how the policy is enforced. “People still go buy swishers for minors knowing it’s against the law” Social media These images were all posted on social media, A coresearcher used this photo because she “Like, because a lot of rappers nowadays, they smoke found on Instagram, Facebook, Snapchat, or thought it was smoke from a (nicotine) electronical cigarettes. I know Kanye West has one, and searching on the web. vape pen but later was told it was from a I know 2 Chainz has one. . . they’re mostly like on social (marijuana) vape pen. This picture shows media doing that. So, I think they see a lot on social the amount of smoke that vape pens media and our generation is stuck on social media a lot. release is a massive amount of smoke and So, that’s probably why e-cigarettes are so—yeah.” you can create the same amount of smoke using nicotine vape pens apparently. “she’s young and she could of went to school with me” (continued) 10 Table 2. (continued) Theme name Definition Notes/significance Sample photo Example quote from geo-narrative Community Images depicting advocacy or a need for Make some webinars or PSA’s on how “once they turn 18, they all say, oh, we can go buy our education/ advocacy. Taking action against tobacco the tobacco marketers are targeting own cigarettes, to have like a couple packs in the purse, advocacy promotion and proliferation, including ways our community and leaving us with with them. I’ll be like, why do you smoke this? This is to reduce tobacco use or tobacco companies’ nonbiodegradable product wastement and like, really disgusting. Like, I usually be like, you’re going efforts to gain or keep new customers, leaving us with health issues because there to die. And, I said, and I’m going to be at your funeral, such as policies or education, educational is no health education on tobacco. laughing, because you’re smoking cigarettes. Like, it—it campaigns, or the need for education; people just—it stinks and it’s in your clothes. It sits in your (This photo is not from data who could take these actions; topics that clothes. So, you—you can just be in the car with all the should be included in education, such as collected; this is used as picture windows rolled down and it sits, and it still sits, and it for intended future.) teaching that advertising or video games are somehow gets in your clothes, and it stinks. And, it’s not realistic, or need for education about just very disgusting.” the effects of the products, or ways the “. . . they may feel like e-cigarettes are better or safer community can address tobacco-related because they use them a lot. I see them using them a problems such as litter. lot, like when I go to BART or when I’m waiting for BART like on platform and stuff, there’s a lot of people, like, with their e-cigarettes, like just blowing smoke and how you know they’re e-cigarettes, they hold a lot more smoke like when they blow it out and stuff.” “I’ve got like two friends that smoke cigarettes and—I’ll be like throwing them. Like, when they pull it out in front of me. But—because they also—they just know I don’t like that. Like, just don’t pull out no cigarette in front of me. Because I’m going to throw it. But, yeah, I know a lot of friends who smoke the, um, the swishers. They’re like the . . . blueberry, cigarillos.” Chopel et al. 11 and packaging. There was further overlap between the Discussion themes of product placement and colors and flavors, as mul- Challenges/Lessons Learned tiple stores had a large inventory placed at the front of the stores, promoting all flavors and showcasing the many eye- Partnership between multiple organizations. A unique feature catching colors. In gathering data from multiple locations in of the study design was the three-way partnership between different communities, the coresearchers noted especially CAHC, CTCRE, and Youth Radio. Each organization con- that the marketing strategies changed in different locations, tributed particular strengths. However, due to organizational specifically that many of these youth-targeted techniques restructuring, the three original organizations were unable to were more prevalent in low-income communities in Down- complete the project together. CAHC and CTCRE, in part- town Oakland and East Oakland. nership with a small group of youth leaders from Youth Radio, continued and completed the study after Youth Specific example of marketing theme: The Black Label. A unique Radio’s leadership decided to shift the focus of the organiza- marketing tactic that the research team noticed was e-ciga- tion and discontinued their participation on an organizational rette liquid with the “Black Label” name. Black Label is a level. However, Youth Radio supported their employed product line of a name brand intended to make customers youth journalists to maintain involvement with the study by feel like they are purchasing an expensive, dark, and danger- accommodating coordinated schedules. When Youth Radio ous product crafted with sophistication. The “Black Label” disengaged from the partnership, the study lost one of its effect was originally developed for hard alcohol. Popular three Co-PIs as the Youth Radio Community Health Director brands such as Johnnie Walker, Jim Beam, Bacardi, and Cap- was terminated as part of the reorganization. The remaining tain Morgan currently have product lines with the Black two Co-PIs explored multiple options for the study, includ- Label name. This later branched out to beer, for example, ing (a) ending the study, (b) recruiting another youth-serving Carling Black Label beer. Then the technique was picked up organization to partner with, (c) building capacity among by soft beverage companies and applied to such products as remaining partners to implement the study with CAHC and Black Label Pure Energy Drink, Hemp Black Label energy CTCRE only. At the time of this decision, both youth part- drink, and Mountain Dew Black Label soda. Most recently, it ners and steering committee members had invested consider- is used for e-cigarette liquid (see Table 1 for a sample photo). able time in the study, training to increase tobacco marketing knowledge and research skills had been completed, and deci- Oakland community-focused and action-oriented themes. We sions had been made including honing the research question took special interest in themes and subthemes that were and how and where to collect data. To honor the commitment impacted the city and culture of Oakland. Themes such as made and demonstrated by multiple stakeholders, the group trash and litter reflect the growing issue of tobacco trash that prioritized continuing the study if possible. Although the is littered on the streets, street gutters, and storm drains. possibility of working with other youth-serving organiza- Trash and litter also serves as secondary advertisement with tions was explored, various barriers prevented many of the the bright colors and enticing flavors accessible to all types youth participants from participating as part of a new organi- of pedestrians. In this urban community, youth are very con- zation. A survey of all 12 youth journalists engaged in the nected to social media. For this reason, the youth researchers project revealed that five were committed to continuing felt it was essential to turn to their social media feeds as a site intensive participation and capable of making that commit- for data collection. They found that social media played an ment if the functions of supporting youth were moved to integral role in the promotion of e-cigarettes and other prod- CAHC, these five youth became the team of coresearchers, ucts as new and trending both within their own local com- and two who remained engaged through data analysis, find- munities and also around the world. They identified this as ings dissemination, and writing are coauthors of this article. another adolescent-targeting advertising tactic, as the ads Importantly, CAHC is located in close proximity to Youth appeared on apps used by themselves and their peers, and Radio, so geography and transportation were familiar to often included free trials and samples, which they identified youth participants. as a possible way to create new addictions/new long-term Various lessons were learned from this challenging situa- customers out of young people. tion. First, when developing organizational partnerships, In accordance with the photovoice tradition, the youth especially between multiple organizations (as is necessary researchers identified opportunities for community educa- for almost all CBPR projects to equitably engage scientific/ tion, local advocacy with businesses, and policy ideas for academic researchers in partnership with community mem- tobacco reduction and community action in their analyses of bers and community-based practitioners), it is important to multiple photos and narratives, without specifically being ensure that organizational leadership is aware and supportive prompted to search for such concepts. They also collected of the project from the beginning. One way to do this is to data on evidence of policy in action, particularly around the request a board resolution or minutes from a board meeting age increase, which took effect as a new statewide policy where they approved the partnership and affiliated the proj- during the time we were engaged in data collection. ect. Active engagement of persons in leadership positions in 12 SAGE Open each organization may also enhance continuing commitment This resulted in a marked reduction in participation by some. to the project. Although this can be time-consuming, and is However, with strategic outreach asking for renewed com- not a guarantee against dissolution, the process of securing mitment, we were happily surprised to find a new health high-level involvement could provide insight into organiza- department representative assigned to the task who became tional commitment. Given that CBPR requires intensive, one of our most active steering committee members. The les- cross-organizational collaboration, this is an essential lesson son we derived from this was that while it is to be expected for both academic and lay CBPR practitioners. that enthusiasm and levels of participation will wax and Furthermore, it is important when developing partner- wane with competing workloads, different phases of the ships between multiple organizations to understand that study, and life circumstances, in a CBPR study that depends more partners means more vulnerabilities. While partners on the voices and presence of multiple stakeholders, it is just bring particular strengths, they also complicate the structure as important to proactively plan to maintain engagement of of the study. It is a good idea to articulate contingency plans adult stakeholders as it is for youth. Clarity about the expec- ahead of time. For example, high staff turnover and funding tations of steering committee members and their ability to instability is much more a part of professional life in non- meet these obligations may facilitate this process. profit organizations than it is in academic organizations, where individual faculty funding fluctuates, but the institu- Safety planning. In CBPR, the line between participant and tion tends to be quite stable. For this reason, having more researcher is intentionally blurred. CBPR is based on a belief than two organizational partners could also strengthen the that the people who are confronting a problem are the best project as it creates sustainability beyond the commitment of suited—with allies—to deeply investigate and address it. any one organization. For example, if either CTCRE or This means that people, who are conducting research come CAHC had been partnered with just Youth Radio, neither from the same community, are peers with people who are the organization would have been able to continue this study on participants. Social scientist researchers are trained to under- its own, at least as a CBPR study. To ensure equity in study stand and consider the safety and well-being of all research leadership and decision-making, it is best practice that at participants or subjects. Furthermore, it is built into research least one Co-PI be located at a community-based organiza- institutions, including funders, that human subjects studies tion. However, a plan in case a Co-PI leaves a partner orga- cannot be launched until an independent board—the institu- nization should be articulated before the study launches. In tional review board (IRB)—has approved the plan. We are some cases, the study may go with the Co-PI to their new less adept at planning for safety of participant-researchers professional home, in other cases, the organization will be from the community. responsible for identifying and training a new Co-PI within For our study, the youth coresearchers went with adult the organization. Similarly, when more than two organiza- allies in pairs to engage in data collection. When they went tions are partnering for a CBPR study, representatives from into stores in particular, store owners could feel threatened all organizations should develop a plan for continuing or not about their business, which could make them unfriendly. in the case that one partner is unable to, or decides not to, More than once, this unfriendliness escalated to racially continue coleading the study. based psychological aggression toward youth coresearchers This plan should take into account the unique capacities in the process of data collection. In one instance, someone of each organizational partner. CAHC was able to step into working at a store chased the youth out of the store and Youth Radio’s role of supporting the youth participant- called security, treating the youth coresearchers (young researchers because staff were interested, it was geographi- women of color—Latina and African American) very differ- cally close to Youth Radio, and they had some institutional ently from their adult colleagues (a White man and an Asian knowledge about effective practices for working with youth. American woman). This was a clear instance of intersec- However, there was a learning curve and the youth core- tionality, the fact that these youths were both young and searchers found themselves in a position where they were women of color combined so they were perceived as having informing and training CAHC staff on how best to work with low power and thus easy targets for the store employee’s them. In addition, hiring youth into an organization that does aggression. The fact that they were researchers employed in not typically employ youth requires nontrivial adjustments in research activities likely did not even occur to the employee hiring and supervision practices. given that young women of color are often excluded from the sanctioned process of knowledge creation known as Engaging multiple stakeholders. In this unexpected transition research. We debriefed as a group and decided to draft a let- process, our first concern was to sustain engagement of the ter to the store owner. However, legal counsel recommended youth coresearchers. Because of this, we were less concerned against sending the letter after investigating the situation. with sustaining engagement of our adult steering committee Other steps we incorporated to improve safety for core- members. Although we planned for sustained engagement by searchers included carrying printouts of the “elevator the third Co-PI with support from their new employer-orga- speech” about the study in addition to memorizing and prac- nization, we were less strategic about maintaining consistent ticing presenting it, providing youth with petty cash so that contact and structure with all steering committee members. they could make a purchase and thus be classified as Chopel et al. 13 customers whenever entering stores, and restricting data people become conscientized, or aware of the structures collection to neighborhoods where they were known or were maintaining oppressive conditions, they become motivated to a recurring customer. We recommend that in future CBPR address them (Freire, 2000). In addition, they eagerly partici- studies, safety planning for community researchers be incor- pated in local advocacy campaigns for restrictions on flavored porated into required IRB protocols. and menthol tobacco and e-cigarettes. As they had learned about some of the “ridiculous” gaps in policy, such as the Evolution of the research question and flexibility in methods. The FDA not having authority to regulate e-cigarettes at the start initial research question posed was focused on youth percep- of the study period, it was empowering for them to have the tions of electronic cigarette marketing, but as the research opportunity to voice their concerns and engage in health pol- took place, the question evolved to include not only elec- icy making on a local level. tronic cigarettes, but also a broader group of flavored and An important lesson for this and future CBPR projects menthol tobacco products. This was consistent with our aim is that research training does not typically include training to allow the group to determine the most relevant aspects of for youth (or for that matter adult) coresearchers to engage the research as experience with the data collection pro- in policy advocacy. Understanding policy-making pro- gressed. This practice differs from research projects where cesses, and effective avenues for advocacy, is a distinct hypotheses are posed a priori and remain static. The collabo- knowledge base and skillset. Some members of our core ration with youth coresearchers included integrating their research team (two youth and two adults) were able to views of what products were relevant and salient as part of access an opportunity through our local health department shared decision making, which ultimately led to the inclu- that built their capacity for policy advocacy and connected sion of a broader array of products that originally proposed. them to seasoned advocates working on tobacco control. This decision also increased the relevance of the research to They quickly became a strong asset in the advocacy strat- local policy action, as both San Francisco and Oakland con- egy, and the two local ordinances they advocated for both sidered policies limiting the sale of flavored and menthol passed: groundbreaking, expansive bans on sales of men- tobacco products following data collection; strictly limiting thol and other flavors of tobacco and e-cigarettes. We rec- the research question to electronic cigarettes would have ren- ommend a two-part training strategy in other youth dered the data much less relevant to these community actions. participatory action research projects, which would enable Similarly, while traditional research projects typically define youth to explore various avenues of change-making and data collection methods at the outset, including sample size embody the connection between research and action that is calculations and other plans, this project allowed the team to embedded in a CBPR orientation. decide on the best methods, and added and modified meth- ods based on experience with the data collection. When Policy and community engagement. Getting involved with the faced with challenges completing photovoice assignments, policy-making process was a struggle with no prior knowl- an alternative geo-narrative approach was considered, and edge or training. Even though training was provided over the pilot tested, to allow for a more geographically driven and course of a year, the process was still challenging, especially broader contextual approach to addressing the research ques- due to the fast pace of change in the local policy environment. tion. Finally, we adapted photovoice methods to integrate Two opportunities for the coresearchers allowed them to put with youth coresearchers’ current use of mobile devices: their newly acquired skills to the test when they presented Most data were collected on coresearchers’ own cell phones, research and findings to local community members with the and some found it most convenient to use Snapchat to collect aim of engaging them in grassroots efforts and then commu- and confidentially store data. The team developed methods nicating the same information in a different way when testify- to securely collect and store data from Snapchat consistent ing at local city council meetings. A third opportunity enabled with privacy and IRB protocols, with leadership and guid- the youth researchers to combine presentation of our study ance from the young social media experts. findings with calls to action for policy advocacy at a local Oakland high school. Students were most interested in learn- Youth as resources. To prepare youth to function as core- ing about how tobacco companies advertise toward people of searchers, they were trained in content areas (such as the state color and the history of menthol. Students expressed that they of the science on e-cigarettes, the history of tobacco compa- are bombarded by messaging from tobacco companies within nies’ marketing tactics, and social justice aspects of tobacco the places they spend time. Students were also unaware of control research and education) in addition to research and what is considered a tobacco product. One example is the communication skills. We found that the trained group of practice of using cigarillos to smoke marijuana: youth were young people who were knowledgeable about a health issue not aware that even if the loose tobacco on the inside of a became a valuable resource for policy and community advo- cigarillo has been removed, by mixing the marijuana with the cacy. They naturally began advocating in their communities outer tobacco wrapper nicotine is still being inhaled. Students and families, discussing the harms of tobacco and e-cigarettes showed an interest in learning how tobacco is affecting their with loved ones and even local corner store owners. This is health not just for them, but for their siblings, parents, other not surprising, as empowerment theory posits that when family members, and their future kids. 14 SAGE Open and unforeseen policy opportunities, it also weakened our Limitations ability to explore e-cigarettes more in-depth. There were three main limitations of our study. The first is Third, the delays that required us to expand the timeline the use of just one major methodology. By not conducting of the project exposed us to high turnover in the youth interviews, focus groups, or using surveys, we were unable research team. As a result, much of the study resources were to collect data from a representative sample of youth. This spent building the capacity of youth who either did not ulti- trade-off allowed us to train youth as coresearchers and build mately contribute to the research at all, or participated in their capacity to not only collect data, but also to analyze it, design decisions but not collecting data, or collected data but communicate about our findings to multiple audiences, and did not engage in data analysis. While it is possible that the to be activated as advocates addressing the very issue they training was a benefit to those young people, in some cases, had developed expertise in. Although we also explored the it did not contribute to answering the research question. use of geo-narratives, and that methodology did complement our photovoice findings, the capacity to rigorously analyze the data collected via geo-narrative did not yet exist within Conclusion our team. Second, by collectively refining our research question in By its very nature, CBPR requires the participation of more the participatory process, we moved from a more specific people, and thus introduces more uncertainty into the study question to a broader one. Although this increased the scope design and the timeline. In our study, various challenges of the study, thereby enabling the team to respond to current resulted in a constantly changing timeline (see Figure 3), yet, Dec 2014 Project start Jan – June 2015 Training in research methods, tobacco marketing, health impact of tobacco, (12 youth interns) Feb – March 2015 IRB application and approval April 2015 Research Question selection meetings with youth and steering committee August 2015 Youth Radio withdrew from project, along with one co-investigator (who joined the Steering Committee) Sept 2015 Project reboot with CAHC hiring 5 of the original youth interns as co-researchers Oct 2015 – March 2016 Additional training in research methods, human subject research, tobacco targeted marketing, photovoice methods, geonarrative methods, use of social media for data collection, and tobacco policy and advocacy Oct 2015 – Oct 2016 Data collection – photovoice April 2016 Youth attend Youth Tech + Health Conference Sept 2016 Data collection - geonarrative Nov 2016 – Feb 2017 Data analysis meetings and retreats, creating codebook, coding data, analytic discussions (3 youth, after 2 left for college/new jobs) March 2017 Youth present results at Alameda County Teens Tackling Tobacco Conference, California Youth Advocacy Network YouthQuest Conference, and preparing a webinar April 2017 Youth attend Oakland City Life Enrichment Committee meeting to advocate for ban on flavored tobacco products Webinar published online May 2017 Youth present results at Youth Tech + Health Conference May 2017 Gallery art show and closing event June 2017 – Oct 2017 Paper writing (2 youth committed to writing, 1 graduated) Sept 2017 Oakland City Council passes ban on flavored tobacco sales, including menthol November 2017 Paper submitted to journal Figure 3. Study timeline. Chopel et al. 15 we were reminded of the value of a CBPR approach in two equipment and software, and Julia McQuoid and Sarah Olson for facilitating and recording the geo-narrative interviews. We would specific ways. First, the necessary flexibility allowed our also like to show our gratitude to Debora Pinkas, Deputy General focus to migrate beyond that of e-cigarettes, based on our Counsel of Public Health Institute, Olivia Thomas, Youth Program youth researchers not experiencing e-cigarette use as a domi- Coordinator of CYAN, Phillip Gardiner, Co-Chair and Valerie nant problem in their circles compared with flavored tobacco Yerger, Founding member and “Honorary” Chair of African products such as cigarillos. This (anecdotal) observation was American Tobacco Leadership Council for sharing their wisdom re-affirmed by data that were released well into our data col- with us during the course of this research. lection period, demonstrating that for the first time, since mass production of e-cigarettes began, e-cigarette use initia- Declaration of Conflicting Interests tion among youth was declining (Jamal et al., 2017). Second, The author(s) declared no potential conflicts of interest with respect the membership of our steering committee enabled us to to the research, authorship, and/or publication of this article. respond rapidly to newly developing opportunities for action. Youth researchers would learn about the inequitable disease Funding outcomes caused by big tobacco companies using targeted marketing and wanted to act on it. Because one of our steer- The author(s) disclosed receipt of the following financial support ing committee members was from the sponsoring organiza- for the research, authorship, and/or publication of this article: This tion for Youth Quest, a statewide information and education research was supported by Grant 23BT-0009 from the Tobacco Related Disease Research Program of the University of California’s event at the state capitol, the youth researchers were invited Office of the President. to speak at the conference and were able to utilize their newly created knowledge for advocacy action by meeting with State legislators; and because the local public health depart- ORCID iD ment was represented on our steering committee, we were R. Eugene Lee https://orcid.org/0000-0001-8584-9721 able to successfully apply for young people to join the local county Tobacco Control Policy Leadership Institute training References and be connected to experienced, well-known, and highly Allen-Price, O. 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SAGE Open – SAGE
Published: Jul 4, 2019
Keywords: Community-based participatory research; youth participatory action research; tobacco; e-cigarettes
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