Application of the PEN-3 Model to Tobacco Initiation, Use, and Cessation Among

American Indian and Alaska Native Adults

Author(s): Vanessa Y. Hiratsuka, Susan B. Trinidad, Jaedon P. Avey and Renee F.
Robinson
Source: Health Promotion Practice , Vol. 17, No. 4 (July 2016), pp. 471-481
Published by: Sage Publications, Inc.

Stable URL: https://www.jstor.org/stable/10.2307/26746797

JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide
range of content in a trusted digital archive. We use information technology and tools to increase productivity and
facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org.

Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at
https://about.jstor.org/terms

Sage Publications, Inc. is collaborating with JSTOR to digitize, preserve and extend access to
Health Promotion Practice

This content downloaded from

168.176.5.118 on Mon, 15 Mar 2021 18:42:52 UTC
All use subject to https://about.jstor.org/terms
648909
research-article2016
HPPXXX10.1177/1524839916648909Health Promotion PracticeHiratsuka et al. / APPLICATION OF THE PEN-3 MODEL

Tobacco Cessation

Application of the PEN-3 Model to Tobacco

Initiation, Use, and Cessation Among American
Indian and Alaska Native Adults
Vanessa Y. Hiratsuka, PhD, MPH1
Susan B. Trinidad, MA2
Jaedon P. Avey, PhD1
Renee F. Robinson, PharmD, MPH1

American Indian (AI) and Alaska Native (AN) commu-

nities confront some of the highest rates of tobacco use
>>
Introduction
and its sequelae. As part of a formative research project Tobacco use is the leading cause of preventable ill-
investigating stakeholder understandings, preferences, ness and death in the United States. Rates of tobacco
and needs surrounding the use of pharmacogenetics use are higher among American Indian (AI) and Alaska
toward tobacco cessation treatment, we sought to char- Native (AN) people than in any other U.S. racial/ethnic
acterize sociocultural issues related to tobacco use and group (Alaska Department of Health and Social
cessation. We used the PEN-3 cultural model to frame Services, 2007). Although the average number of ciga-
the research question and analysis of stakeholder inter- rettes smoked per day is lower among AN smokers than
views with 20 AI/AN patients, 12 health care providers, among U.S. White smokers, tobacco-related disease
and 9 tribal leaders. Our study found high knowledge burden is higher (Bliss et  al., 2008; Wassenaar et  al.,
levels of the negative health effects of tobacco use; 2011). In addition to cigarette smoking, AN people use
however, most patient participants ascribed negative commercial tobacco products and iq’mik (a homemade
health effects only to regular, heavy tobacco use and smokeless tobacco product containing alkaline ash;
not to light use, which is more common in the popula-
tion. The majority of patient participants did not 1
Southcentral Foundation, Anchorage, AK, USA
endorse use of tobacco cessation treatment despite 2
University of Washington School of Medicine, Seattle, WA,
evidence of efficacy among AI/AN adults. Health pro- USA
motion messaging to target low–tobacco consuming AI/
AN people is needed. Additionally, messaging to pro- Authors’ Note: This research was conducted with guidance from
mote tobacco cessation treatment using successful AI/ the Southcentral Foundation Research Oversight Committee who
AN former tobacco users to improve community per- we would like to thank for their considerable review of the
ception of tobacco cessation treatment is recom- research plan. The authors would like to thank Austen Rogers,
mended. Sandra Lapp, and Lisa Dirks for assistance in participant
recruitment and scheduling. We would like to thank Lisa Dirks
and Lily Gadamus for their support in participating in data
Keywords: classifications: models, theoretical; qual-
collection, and we would like to thank Lily Gadamus also for her
itative research; tobacco use; Indians, participation in coding of interviews. We would like to thank the
North America members of the Southcentral Foundation and Alaska Native
Tribal Health Consortium research review committees for their
continued review of research at the Alaska Native Medical Center
campus. Finally, we would like to thank the American Indian and
Alaska Native participants in our study for sharing their
viewpoints with our research team as they participated in the
Health Promotion Practice research project (NIGMS/NIH NARCH U261IHS0079). Address
July 2016 Vol. 17, No. (4) 471­–481 correspondence to Vanessa Y. Hiratsuka, PhD, MPH, Southcentral
DOI: 10.1177/1524839916648909 Foundation Research Department, 4105 Tudor Centre Drive, Suite
© 2016 Society for Public Health Education 210, Anchorage, AK 99504, USA; e-mail: vhiratsuka@scf.cc.

471

This content downloaded from

168.176.5.118 on Mon, 15 Mar 2021 18:42:52 UTC
All use subject to https://about.jstor.org/terms
Renner et al., 2005) at a higher proportion than the U.S.
national average (Alaska Department of Health and
Social Services, 2007). Many factors affect tobacco use,
tobacco-associated mortality and morbidity, and
response to tobacco and tobacco cessation treatment
(Batra, Patkar, Berrettini, Weinstein, & Leone, 2003;
Benowitz, Hukkanen, & Jacob, 2009; Vink, Willemsen,
& Boomsma, 2005).
Few studies have examined factors influencing
tobacco use and cessation in the AI/AN population,
and within the AN population only one study (Fenn,
Beiergrohslein, & Ambrosio, 2007) addressed cessation
among urban AN people, the largest group of AN peo-
ple. Patten et al. (2010) hypothesized that low partici-
pation rates in tobacco cessation interventions among
rural, pregnant AN women might be due to social
stigma and desirability, community and cultural con-
texts that were barriers to program participation. Patten
et  al. (2009) also describe rural AN adolescent prefer-
ences for tobacco cessation programs and found unique
cultural views on adolescent tobacco use such as nega-
tive self-concept when using iq’mik and parental
knowledge of tobacco use. Tobacco use behaviors and
understandings within the adult, urban AN cultural
context are not well described, and yet they are factors
in cultural adaptation of tobacco cessation treatment
steps of asking about tobacco use, advising on quitting,
assessing willingness to quit, assisting in the quit
attempt, and arranging follow-up to support individu-
als in the quitting process (U.S. Public Health Service,
2008).
Stakeholder engagement in the development of
interventions targeting racial/ethnic minorities is par-
ticularly important given community member and
leader perceptions on health research (Ball & Janyst,
2008; Christopher, 2005; Harding et  al., 2012; Hodge,
2012; Holkup et al., 2009; Laveaux & Christopher, 2009;
Vasgird, 2007). Many communities remain concerned
about damages done to racial/ethnic minority popula-
tions in the name of research (Adams, 2000; Bowekaty,
2002; Filippi et al., 2012; Hiratsuka, Brown, & Dillard,
2012; Lewis & Boyd, 2011; Schnarch, 2004; Shore,
Drew, Brazauskas, & Seifer, 2011). Understanding how
stakeholders envision diagnosis and treatment for
tobacco cessation may facilitate effective communica-
tion during treatment (Anderson & Funnell, 2010;
Street, Makoul, Arora, & Epstein, 2009).
Although this research was performed within the
context of a larger qualitative study that included an
exploration of the use of pharmacogenetics, the aim of
this study is to describe perspectives on tobacco use
and cessation among AI/AN adults, in the context of an
AI/AN–operated health care facility. To take into con-
472  HEALTH PROMOTION PRACTICE / July 2016
This content downloaded from
168.176.5.118 on Mon, 15 Mar 2021 18:42:52 UTC
All use subject to https://about.jstor.org/terms
sideration the sociocultural issues related to tobacco
use and cessation, we sought to better understand
tobacco use and cessation using the PEN-3 cultural
model (Airhihenbuwa, 1992) to frame analysis.
>>
Theoretical Framework: The PEN-3
Cultural Model
The PEN-3 model was designed and first imple-
mented as a framework for health promotion in Africa
and has increasingly been applied in the United States
in settings where traditional methods of health promo-
tion have fallen short due to lack of emphasis on culture
and its impact on health outcomes. The PEN-3 model
addresses the influence of culture and the importance
of culture in identifying a strengths-based approach to
public health interventions (Airhihenbuwa, 1992;
Airhihenbuwa et  al., 2009; Iwelunmor, Newsome, &
Airhihenbuwa, 2014). The PEN-3 cultural model has
been used to address a multitude of health issues (e.g.,
HIV, smoking, nutrition) with complex clinical and cul-
tural contexts that affect health behaviors and health
outcomes (Iwelunmor et  al., 2014). Use of the PEN-3
model allows researchers to examine cultural practices
that are crucial in explicating the mechanisms of posi-
tive health behaviors, while acknowledging unique
cultural practices that have a neutral impact on health
and distinguishing negative factors that are likely to
have an adverse influence on health behaviors
(Airhihenbuwa et  al., 2009; Iwelunmor et  al., 2014;
Iwelunmor, Idris, Adelakun, & Airhihenbuwa, 2010).
Erwin et  al. (2010) have noted that the PEN-3 model
allows for thematic interpretation of qualitative data in
the analysis process to unpack rich descriptions of
beliefs and concepts into discrete domains that can then
be contextualized as specific behaviors and health mes-
sages. Additionally, the model is helpful in identifying
how individuals perceive their health in relationship to
others in their social network and thus focuses research
on the context that nurtures the health behavior of inter-
est as well as the role of the collective (e.g., kin) in
influencing health behaviors (Iwelunmor et al., 2014).
The PEN-3 model places culture at the center of the
study of health beliefs, behaviors, and health outcomes
through lens of three interlocking domains (Figure 1):
Cultural Identity, Relationships and Expectations, and
Cultural Empowerment (Airhihenbuwa, 1995). Each
domain includes three factors that form the acronym
PEN: (1) Cultural Identity domain—Person (individual
affecting health decisions), Extended Family (the role
of kinship in decisions that may affect an individual),
Neighborhood (the context of the community and val-
ues that shape health decisions); (2) Relationships and

Figure 1  The PEN-3 Model
Expectations domain—Perceptions (the knowledge,
attitudes, values, and beliefs that may promote or
impede health behavior), Enablers (community and
structural factors that affect health behavior), and
Nurturers (health behavior reinforcing resources from
the target audience’s social network); and (3) Cultural
Empowerment domain—Positive (identifying positive
factors that lead the target audience to engage in a par-
ticular health behavior), Existential (understanding the
qualities that make the culture unique, that should be
acknowledged and incorporated into health interven-
tions), and Negative (identifying negative factors that
lead the target audience to not engage in a particular
health behavior; Iwelunmor et  al., 2014; Scarinci,
Bandura, Hidalgo, & Cherrington, 2012). The PEN-3
cultural model is used for intervention development by
identifying and organizing individual-, group-, and
community-level factors allowing for the integration of
significant influences of ethnic cultural perspectives to
health issues making this model useful in the descrip-
tion of perspectives on tobacco use and cessation
among AI/AN adults.
>>
Method
This qualitative study used semistructured inter-
views to elicit perceptions of tobacco use, cessation,
and the utility of pharmacogenetics to guide tobacco
cessation treatment at Southcentral Foundation (SCF)
primary care clinics. The Anchorage Native Primary
Care Center (ANPCC) is operated by SCF. The ANPCC
This content downloaded from
168.176.5.118 on Mon, 15 Mar 2021 18:42:52 UTC
All use subject to https://about.jstor.org/terms
provides comprehensive health services for more than
65,000 AI/AN people and operates through a prepaid,
patient-centered medical home model (Driscoll et  al.,
2013; Eby, 2007).
Participant Characteristics
The sample comprised three groups: patients, SCF
health care providers (e.g., physicians, nurses, pharma-
cists, health educators, and dental hygienists), and
institutional leaders (e.g., department managers). All
participants were older than 18 years. Patient inclusion
criteria were AI/AN heritage, eligibility for services at
the ANPCC, and either current tobacco use or a history
of tobacco use. Health care providers and institutional
leaders were affiliated with the ANPCC.
Participant Recruitment and Data Collection
Patients were recruited from the lobby of the ANPCC
and via flyers. Health care providers and institutional
leaders were recruited via institutional e-mail. Recruits
were screened to ensure eligibility requirements were
met. Interviews were conducted in English at SCF from
October 2013 through January 2014, digitally recorded,
and then transcribed for analysis. A brief demographic
questionnaire was administered following each inter-
view (Table 1). Interviewers used a semistructured
interview guide (Table 2) to complete the interviews.
Participants received a $25 gift card. The project
received approval from Alaska Area Institutional
Review Board and community approval from SCF and
the Alaska Native Tribal Health Consortium.
Data Analysis
We conducted a thematic analysis of the interview
data through an iterative and inductive process (Attride-
Stirling, Humphrey, Tennison, & Cornwell, 2006). A
total of three interviews, one from each participant
subgroup, were selected and reviewed by all three
members of the coding team. The researchers discussed
the data subset, noting salient constructs, until consen-
sus was reached on an initial coding schema, including
20 mutually exclusive codes with code definitions. The
interview data were then divided among members of
the coding team and coded using ATLAS.ti 7.1.8. The
team met weekly, after each person coded three inter-
views each week, to discuss the data and adjust the
coding schema, adding and/or eliminating codes and
revising definitions accordingly. Detailed notes were
kept of each meeting and reviewed at the next meeting
to ensure consistency. As changes were made to the
Hiratsuka et al. / APPLICATION OF THE PEN-3 MODEL  473
 Table 1
Participant Characteristics

Characteristic Patients Leaders Providers All Participants

Gender
 Female 14 9 10 33
 Male 6 0 3 9
Age (years)
 18-29 7 1 0 8
 30-39 1 4 5 10
 40-59 9 4 8 21
  ≥60 3 0 0 3
Highest level education completed
  >High school 0 0 0 0
  High school graduate 4 0 1 5
  Some college 9 1 0 10
  College graduate 3 5 10 18
  Trade or vocational 0 2 2 4
school
Past participant in genetic research
study
 Yes 3 0 0 3
 No 15 9 12 36
Past quit attempt?
 Yes 16 5 5 26
 No 4 4 8 16

coding schema, the lead researcher (VH) recoded data
as needed, applying updated codes to previously coded
data. Once all data were coded through this process of
iterative consensus, the researchers applied the con-
stant comparative method to identify emergent themes
within and across participant subgroups by tobacco use
history (Boeije, 2002; Glaser, 1965). Again, discussions
were held weekly in which the researchers discussed a
priori and emergent themes and reviewed notes from
previous meetings until consensus on thematic catego-
ries and their properties was reached. This article
reports on results tobacco use history. Only responses
from questions pertaining to tobacco use and tobacco
cessation (Table 2) were analyzed and reported here.
Data analysis for this project was also guided by the
PEN-3 model (Airhihenbuwa, 1990, 1992), which
places culture at the core of the development of suc-
cessful health promotion and disease prevention pro-
grams. In this project we found themes and subthemes
within and across patient, provider, and administrative
leader samples. The PEN-3 dimensions (cultural iden-
tity, relationships and expectations, and cultural empow-
erment) were considered as themes were developed.
Primary themes were initiation and early tobacco use,
cultural and social/situational uses of tobacco, per-
ceived benefits and harms of tobacco use, and drivers
of successful cessation. Guided by the PEN-3 model
dimensions, we cross-tabulated the Relationships and
Expectations domain with the Cultural Empowerment
domain (Iwelunmor et  al., 2014). We then organized
themes in terms of the factors that influence tobacco
use in positive and negative ways and factors that
guided perceptions (knowledge, attitudes, and beliefs),
enablers (structural, environmental, and community
factors), and nurturers (reinforcing social factors).
“Positive” referred to perceptions, enablers, and nur-
turers that indicated that an individual was to engage
in healthy behaviors or deterred from engaging in
harmful behaviors (Williams, Moneyham, Kempf,
Chamot, & Scarinci, 2015). “Negative” referred to per-
ceptions, enablers, and nurturers that indicated that an
individual was to engage in unhealthy behaviors or
encouraged to engage in harmful behaviors (Williams
et  al., 2015). We then assessed the intersection of the
Relationships and Expectations and Cultural
Empowerment domains (Table 3) to describe themes at

474  HEALTH PROMOTION PRACTICE / July 2016

This content downloaded from

168.176.5.118 on Mon, 15 Mar 2021 18:42:52 UTC
All use subject to https://about.jstor.org/terms
 Table 2
Interview Guide

Interview Questions Patients Leaders Providers

Views on tobacco use, consequences, and cessation

   1. When did you start smoking or chewing? Has your tobacco use X  
changed over time?
   2. Why do people use tobacco, in your view? X X X
   3. How does using tobacco affect a person’s health and well-being, X X X
for better or worse?
   4. What are the advantages and disadvantages of quitting tobacco? X X X
Experience with tobacco use and cessation at Southcentral Foundation
   5. Could you share your personal tobacco story with me? X  
   6. What is your experience with quitting tobacco? X  
   7. Can you tell me how Southcentral Foundation currently X X
approaches tobacco use and cessation with customer owners?
   8. In your experience, which tobacco cessation approaches are X
most useful/successful? Why do you think that is?
   9. How do you approach tobacco use and tobacco cessation with X
customer owners?
  10. What questions do customer owners tend to ask about tobacco X
cessation?
Concluding remarks
  11. What else should we know about this topic? X X X
  12. How was this interview for you? X X X

NOTE: Many questions were reworded to suite the role of the participant. Question follow-up probes were removed from interview
guide for brevity.

the intersection of the domains to determine domain
intersections (i.e., positive and negative perceptions,
positive and negative enablers, positive and negative
nurturers) within each theme.
>>
Results
Demographic characteristics are reported in aggre-
gate to avoid risk of participant identification. The
sample consisted of 20 patients, 12 health care provid-
ers, and 9 tribal leaders. As seen in Table 1, the major-
ity of participants were women (79%), were older than
age 40 years (58%), had at least some college education
(84%), had not participated in genetics research (85%;
8% unsure), and had attempted to quit tobacco at some
time in their lives (65%).
Initiation and Early Tobacco Use
We asked patient participants to describe how they
began using tobacco and their early experiences with
tobacco. Most participants said they had used cigarettes,
with a minority reporting use of smokeless tobacco or
iq’mik, a homemade mixture of chewing tobacco and
punk ash (Hurt et al., 2005; Renner et al., 2005). Many
recalled tobacco initiation as elementary school–aged
children with more regular use in adolescence.
Perceptions (Positive).  Some patients described
unpleasant initial experiences with tobacco use, find-
ing it distasteful or socially uncomfortable. Negative
experiences were not always sufficient to keep a person
from using tobacco.
Perceptions (Negative). Many patients described a
desire to fit in socially, to “look cool” in the eyes of
peers, as a strong motivator for tobacco initiation. Par-
ents’ and other adults’ attitudes and behaviors around
youth tobacco use also played an important role, as
illustrated by one participant initiation story:
You know, second grade, I remember my brothers
and I stealing a carton of cigarettes. Probably six

Hiratsuka et al. / APPLICATION OF THE PEN-3 MODEL  475

This content downloaded from

168.176.5.118 on Mon, 15 Mar 2021 18:42:52 UTC
All use subject to https://about.jstor.org/terms
 Table 3
PEN-3 Table of Analysis With Examples of the Relationships/Expectations and Cultural Empowerment

Cultural Empowerment

  Domains Positive Existential Negative

Perceptions Household, workplace, American Indian Socially encouraged use—

and community policies traditional tobacco use fitting in/acting cool
Relationships/expectations

Enablers Being in tobacco-free
environments and
changing personal life
patterns/behaviors
Nurturers Sharing of tobacco-related
poor health with others;
consistent follow-up/
support with individuals
in quit process
for ceremonial/spiritual
purposes
Personal financial cost of
clinical tobacco
treatment services, and
tobacco-related health
effects
Alaska Native traditional
medicine and interest
in alternative
treatments
Family and friends giving
tobacco at initiation;
negative health effects
message not resonating
with low use
Being in places that allow
tobacco use—personal
vehicle and relief of stress;
Reliance on self to quit/
power through/cold turkey

we started. Probably wasn’t until eight that I could
inhale. By the time I was 13, my dad got tired of
beating me and just said, you know, “Just go
ahead.” My parents were both still smoking. In the
house. In the car.
Enablers (Positive).  Administrative leaders saw changes
in social policy as discouraging initiation. For some
patients, home policy regarding tobacco use was a deter-
rent, leading them either to avoid tobacco altogether or
limit their use of tobacco in the home. School policies
against smoking had a similar effect for some patients, as
in this example from an individual who attended board-
ing school: “[I]n high school, [if] they catch you smok-
ing, you get on restriction, and I never wanted to get in
trouble, so I’d quit for the nine months I was there.”
the—the tobacco peer pressure and stuff. You
know, back when I was a teenager.
Nurturers (Positive).  Current and former tobacco users
reported that advertising that portrayed tobacco as a
symbol of freedom and rebellion played a part in their
trying tobacco initially.
Nurturers (Negative). The attitudes and behaviors of
older family members played a strong role in forming
patient attitudes toward the acceptability of tobacco
use. Provider and administrative leader perceptions of
the reasons AI/AN youth begin using tobacco echoed
what we heard from patient participants—social facili-
tation of accessing tobacco products and condoning
youth use. A provider participant said,

Enablers (Negative). Patient participants described I think that a lot of people start smoking when
environmental factors that contributed to their decision they’re young, and I think that there’s a cultural
to use tobacco. The easy availability and relatively low component to it. . . . When I say cultural, I’m not
cost of tobacco products in the past had contributed to referring specifically to Alaska Native . . . you know,
early initiation. Some patients reported that a sense of it’s kind of a cultural norm. It’s culturally accepted
cultural displacement influenced their behavior, as in and culturally appropriate, and that’s what every-
this statement: body else is doing in your family or in your peer
group, then I’m sure you’re going to do it as well.
[W]e moved to the city when I was like 11 years
old. Culture shock. A lot more stresses and pres- Cultural and Social/Situational Uses of Tobacco
sures and—especially when you’re young and
naive. Mm-hm. Put it that way. Yeah. It’s hard, and Participants were asked if they had or had heard
I think, you know, that probably pressured me into about cultural or spiritual uses for tobacco. “Culture”

476  HEALTH PROMOTION PRACTICE / July 2016

This content downloaded from

168.176.5.118 on Mon, 15 Mar 2021 18:42:52 UTC
All use subject to https://about.jstor.org/terms
was defined by participants in two ways: as traditional
AI/AN cultural practices, in which tobacco may have
ceremonial, spiritual, or other significance (Daley et al.,
2011; Nadeau, Blake, Poupart, Rhodes, & Forster, 2012)
and, more generally, in terms of norms and practices in
a given community, workplace, or family.
Perceptions (Positive).  Few patient participants
reported tobacco having traditional, ceremonial cul-
tural meaning to them, though many were aware of AI
tribal traditional tobacco uses. Some patient partici-
pants believed that the tobacco used in such applica-
tions is different, and less dangerous, from commercial
tobacco. Providers noted the need for cultural sensitiv-
ity around AI traditional tobacco use, as the service
population of SCF includes AI peoples.
Perceptions (Negative). Although most AN partici-
pants said that cultural and spiritual uses were not rel-
evant for them, they noted tobacco use by elders,
particularly the use of chewing tobacco and/or iq’mik
in smaller, nonurban communities, as having cultural
weight. Providers and leaders also identified elders as
being more likely to use chewing tobacco or iq’mik. In a
culture in which elders are honored and respected, this
practice may be understood as a cultural tradition.
Enablers (Positive). Certain situations—such as preg-
nancy or having a new baby in the house—were seen as
providing an impetus to quit tobacco. Community and
workplace policies that made tobacco more expensive
or difficult to get were also seen as mitigating tobacco
use.
Enablers (Negative). Patient participants described a
number of environmental factors that contributed to
situational tobacco use. Tobacco use was seen as a rou-
tine part of the day for certain workplace settings (i.e.,
fishing, oil industry, or warehouse work). Some patients
had jobs where tobacco was less expensive, increasing
use. Some patients said that they smoked more often in
the village than in urban settings.
Nurturers (Positive). As social attitudes and policies
around tobacco use have changed, some individuals
have found smoking to be less comfortable in public
settings. Patient participants noted that different social
norms about tobacco use may apply for women and
men.
Nurturers (Negative). Patient participants tended not
to voice disapproval of tobacco use in these interviews.
This content downloaded from
168.176.5.118 on Mon, 15 Mar 2021 18:42:52 UTC
All use subject to https://about.jstor.org/terms
On the contrary, some associated smoking with compe-
tence and productivity. Certain social situations, often
involving alcohol and/or sports, were seen as condu-
cive to smoking. Tobacco was described as often part of
the social scene when people gather to relax and tobacco
use was seen as being sociable. Challenging situations
(e.g., a hard day at work or a funeral) that create feelings
of anxiety, frustration, grief, or discomfort were cited as
another trigger for tobacco use.
Perceived Benefits and Harms of Tobacco Use
Perceptions (Positive). Patient respondents were well
aware of the negative health effects of tobacco use,
including increased risk of cancer, respiratory disease,
and shortness of breath. Patients who were disinclined
to use tobacco or saw it as harmful often gave more than
one reason, as in this example: “[T]he way I feel about
tobacco is that it stinks, and it doesn’t really help stress
and such, and it’s expensive.”
Perceptions (Negative).  Some patients saw tobacco use
as a way of managing emotions and maintaining “men-
tal well-being.” They said that it helped them relax and
“calm down,” manage stress, relieve anxiety, avoid
boredom, and keep aggression and temper in check.
One patient appreciated the appetite-suppressing
effects of tobacco and said that it could be a useful
weight loss tool; one of the provider participants also
noted that patients—particularly women—use tobacco
to manage their weight. Some patients considered
smoking or chewing an enjoyable pastime with pleas-
ant effects.
Enablers (Positive). Provider participants noted that
understanding how and why patients are using tobacco
is important in working with patients who are inter-
ested in quitting. This information can help identify the
optimal treatment for that individual at that time.
Enablers (Negative). Provider participants noted the
ease of obtaining tobacco and a long history of accep-
tance of tobacco use tend to reinforce tobacco use. For
example,
Nicotine has many uses, many properties, and . . .
it’s easily accessible. You can go to any grocery
store, any gas station, and you’ll be able to get the
product. People aren’t hesitant to share or encour-
age other people to use it. Socially, you know, it’s
kind of pretty acceptable. And just in my experi-
ence, some people use it as a way of leisure, such
Hiratsuka et al. / APPLICATION OF THE PEN-3 MODEL  477
 as taking a break from life, from housecleaning,
from kids, from work, and that’s the only way they
associate it taking a break from those times is using
or smoking a cigarette.
Nurturers (Positive).  A strong theme in interviews with
patients was the perception that a “reasonable” level of
tobacco use does not cause (much) physiological harm.
Many patient participants made a distinction between
problematic tobacco use (sometimes offering a thresh-
old definition, e.g., a pack a day) and an acceptable
level of tobacco use, as exemplified in this comment:
I wasn’t using tobacco that much. They were say-
ing a half a pack [could cause lung damage]. You
know, where I would smoke a cigarette or two a
day. So I felt like it didn’t relate to me as much, but
I saw the potential that could happen.
Nurturers (Negative). Social drivers of continued
tobacco use play an important role in AI/AN use. In
particular, the feeling of community, with one patient
participant stating, “Whenever I’d smell smoke, it
would bring on feelings of relaxation, feeling of being
accepted with [a] couple of friends that I had that
smoked and drank.”
Drivers of Successful Cessation
Perceptions (Positive). All participants were knowl-
edgeable about the health benefits of quitting. Patient
participants mentioned living longer, reducing cancer
risk, and having improved breathing, a stronger immune
system, fewer respiratory infections, increased energy,
and improved overall well-being as benefits to non-
smokers and their family members. Patient participants
were also aware of how quickly the health benefits of
quitting begin to accrue. Administrative leader and pro-
vider views were consistent with those mentioned by
patients, with the addition of increased self-efficacy as
a positive outcome.
Patient participants in this sample felt that quitting
is largely a personal choice. They described tobacco
cessation treatment as potentially helpful but largely
considered quitting a choice that must come from
within. One patient participant summarized this widely
held belief in the statement:
For quitting, I think it’s—it’s a personal decision to
quit, and some people need more assistance than
others and willpower. I think it’s all in the mind,
myself, and—because I—I know there’s like one of
my friends who smoked for years and years and
478  HEALTH PROMOTION PRACTICE / July 2016
This content downloaded from
168.176.5.118 on Mon, 15 Mar 2021 18:42:52 UTC
All use subject to https://about.jstor.org/terms
years but made it—made the decision to quit for
his grandchildren and his personal health but
didn’t have any assistance.
Perceptions (Negative). Participants in all groups
believed that overcoming the physical addiction to nic-
otine was very difficult. Providers and administrative
leaders were aware of the hurdles patients face in trying
to quit. Consistent with patients’ beliefs that tobacco
can be a useful weight management tool, both patients
and providers cited concern with weight gain as a bar-
rier to tobacco cessation.
Enablers (Positive).  Programs that offer different meth-
ods and approaches to tobacco cessation were seen as
having greater potential to help more patients, by all
groups in this study. Patient-driven treatment decision
making was highly valued. Patient participants spoke
of planning for quitting as a helpful strategy, such as
learning how to replace tobacco in situations where
they are accustomed to smoke.
Enablers (Negative).  Some patient participants felt that
they should be able to quit without external support
and regarded accessing cessation support as an abdica-
tion of personal responsibility and self-motivation. One
participant stated,
I just haven’t really tried to use any of the resources
here available, I guess, because I just feel like it’s
something that I should be able to do on my own.
Like just do it, you know, mind over matter.
Many patients were skeptical of the value of clinical
support such as tobacco cessation counseling; they
knew about the risks and harms associated with tobacco
use and did not consider counseling worthwhile if
patients are already educated in this way. In contrast,
providers and administrative leaders tended to see
counseling as an important part of tobacco cessation
programs.
Both patient and provider participants noted that
some patients may be unwilling to try pharmacological
interventions for quitting, with providers noting that
their patients were disinclined to take medication in
pill form. Patients expressed dissatisfaction with the
side effects of nicotine replacement options. Patients
also noted that people may be less willing to invest in
quitting if pharmacological cessation aids cost the same
or more than tobacco.
Nurturers (Positive).  Participants in all groups said that
connections with family and friends could be
strengthened through quitting. Patients said that family
members, especially children, could have a significant
motivating effect on quitting. Patient participants said
that staying away from tobacco-using friends, or tobacco
and alcohol in combination, was helpful in successful
cessation.
Nurturers (Negative). Patients noted that people are
often “grouchy,” “dull,” “inactive,” or “less fun to be
around” when they are making quit attempts. The
social nature of smoking was also a barrier to trying to
cut down or quit.
>>
Discussion
As AI/AN tobacco use rates are the highest of any
racial group in the United States (U.S. Department of
Health & Human Services, 1998), determining effective
tobacco cessation interventions with this population is
important. Surveillance reports indicate that tobacco
cessation treatment is effective among AI/AN adults
(Boles et  al., 2009; Fenn et  al., 2007); however, the
majority of the patient participants in this study did
not endorse use of tobacco cessation treatment. The
apparent disconnect between adult AN patient percep-
tions of clinically supported tobacco cessation and the
evidence base for cessation is an important finding for
tobacco cessation efforts in AI/AN health systems. The
poor endorsement by AI/AN adults of tobacco cessa-
tion support may negatively influence the beliefs of AI/
AN families around clinical tobacco cessation. Media
messaging to AI/AN adults should include messages on
the effectiveness of pharmacological and counseling-
supported cessation.
The cultural context of the AN and AI tribal back-
grounds, rural village and urban center home commu-
nity, and type of contact with the health system were
cultural contexts of significance shaping tobacco use
and cessation behaviors. Patient participant views on
tobacco use and cessation were more likely to be influ-
enced by family and community expectations, most
often in a positive enabling manner (e.g., family sup-
port for individuals quitting; mothers with babies
encouraged to continue with cessation options by fam-
ily). The role of the collective in AI/AN tobacco cessa-
tion underscores the importance of understanding
family positive influence in health-related decisions.
Our study found high knowledge levels of the nega-
tive health effects of tobacco use among the AI/AN
patients. However, most patients described the negative
health effects of tobacco use only when referring to
regular, heavy tobacco use (e.g., pack a day smoking
behavior) and did not ascribe similar negative health
This content downloaded from
168.176.5.118 on Mon, 15 Mar 2021 18:42:52 UTC
All use subject to https://about.jstor.org/terms
effects with light use. In fact, some participants indi-
cated that their belief that light tobacco has fewer health
consequences resulted in their lack of interest in tobacco
cessation. Health education messages should address
the negative health effects of both lighter and heavier
tobacco use, particularly among the AI/AN population,
as surveillance data indicate AI/AN adults consume
less tobacco but have high tobacco use prevalence com-
pared to their non–Native American adult counterparts
(Dilley, Peterson, Hiratsuka, & Rohde, 2013).
This study had several limitations. Patient partici-
pants were current or former tobacco users; among the
former smokers, the time elapsed since quitting varied
greatly in the sample, with some participants quitting
well before tobacco cessation treatment was commonly
offered by the AI/AN health system. The sample was a
convenience sample of AI/AN patients, leaders/admin-
istrators, and their health providers and may not be
representative of the views of these groups. Finally, the
sample included a preponderance of female partici-
pants, and thus views of males may not have been
adequately reflected.
>>
Conclusion
Cultural perceptions, enablers, and nurturers influ-
ence how both AI/AN adults and their health system
staff consider tobacco use and cessation. We found that
AI/AN current and former tobacco users expressed
high knowledge of negative health effects of tobacco
use but low endorsement of pharmacological cessation,
despite evidence of efficaciousness among AI/AN
adults. AI/AN current and former tobacco users did not
perceive tobacco cessation counseling or the use of
pharmaceutics to be helpful in assisting them in quit-
ting tobacco use. Additionally, AI/AN current and for-
mer tobacco users did not believe that adverse health
effects would be created from low to moderate tobacco
consumption. Considerations of positive behavior and
negative behavior perceptions, enablers, and nurturers
can help health educators in developing health promo-
tion messaging to target AI/AN tobacco users to design
cessation programs congruent with cultural and social
perceptions of tobacco use. Promotion of clinical
tobacco cessation treatment with successful AI/AN for-
mer tobacco users as messengers is recommended to
improve community perception of services.
References
Adams, A. (2000). The road not taken: How tribes choose between
tribal and Indian Health Service management of health care ser-
vices. American Indian Culture and Research Journal, 24(3),
21-38.
Hiratsuka et al. / APPLICATION OF THE PEN-3 MODEL  479
Airhihenbuwa, C. O. (1990). A conceptual model for culturally
appropriate health education programs in developing countries.
International Quarterly of Community Health Education, 11, 53-
62. doi:10.2190/lpkh-pmpj-dbw9-fp6x
Airhihenbuwa, C. O. (1992). Health promotion and disease pre-
vention strategies for African Americans: A conceptual model. In
R. L. Braithwaite & S. E. Taylor (Eds.), Health issues in the Black
community (pp. 267-280). San Francisco, CA: Jossey-Bass.
Airhihenbuwa, C. O. (1995). Health and culture: Beyond the
Western paradigm. Thousand Oaks, CA: Sage.
Airhihenbuwa, C. O., Okoror, T., Shefer, T., Brown, D., Iwelunmor,
J., Smith, E., . . . Shisana, O. (2009). Stigma, culture, and HIV and
AIDS in the Western Cape, South Africa: An application of the
PEN-3 cultural model for community-based research. Journal of
Black Psychology, 35, 407-432. doi:10.1177/0095798408329941
Alaska Department of Health and Social Services. (2007). What
state surveys tell us about tobacco use among Alaska Natives.
Retrieved from http://dhss.alaska.gov/dph/Chronic/Documents/
Tobacco/PDF/AKNativeTobaccoReport.pdf
Anderson, R. M., & Funnell, M. M. (2010). Patient empowerment:
Myths and misconceptions. Patient Education and Counseling,
79, 277-282.
Attride-Stirling, J., Humphrey, C., Tennison, B., & Cornwell, J.
(2006). Gathering data for health care regulation: Learning from
experience in England and Wales. Journal of Health Services
Research & Policy, 11, 202-210. doi:10.1258/135581906778476607
Ball, J., & Janyst, P. (2008). Enacting research ethics in partner-
ships with indigenous communities in Canada: “Do it in a good
way.” Journal of Empirical Research on Human Research Ethics,
3(2), 33-51. doi:10.1525/jer.2008.3.2.33
Batra, V., Patkar, A. A., Berrettini, W. H., Weinstein, S. P., & Leone,
F. T. (2003). The genetic determinants of smoking. Chest, 123,
1730-1739.
Benowitz, N. L., Hukkanen, J., & Jacob, P., 3rd. (2009). Nicotine
chemistry, metabolism, kinetics and biomarkers. In J. E.
Henningfield, E. D. London, & S. Pogun (Eds.), Handbook of
experimental pharmacology: Vol. 192. Nicotine psychopharma-
cology (pp. 29-60). New York, NY: Springer.
Bliss, A., Cobb, N., Solomon, T., Cravatt, K., Jim, M. A., Marshall,
L., & Campbell, J. (2008). Lung cancer incidence among American
Indians and Alaska Natives in the United States, 1999-2004.
Cancer, 113(5 Suppl.), 1168-1178. doi:10.1002/cncr.23738
Boeije, H. (2002). A purposeful approach to the constant com-
parative method in the analysis of qualitative interviews. Quality
& Quantity, 36, 391-409. doi:10.1023/A:1020909529486
Boles, M., Rohde, K., He, H., Maher, J. E., Stark, M. J., Fenaughty,
A., & O’Connor, T. (2009). Effectiveness of a tobacco quitline in an
indigenous population: A comparison between Alaska Native
people and other first-time quitline callers who set a quit date.
International Journal of Circumpolar Health, 68, 170-181.
Bowekaty, M. B. (2002). Perspectives on research in American
Indian communities. Jurimetrics, 42, 145-148.
Christopher, S. (2005). Recommendations for conducting success-
ful research with Native Americans. Journal of Cancer Education,
20(1 Suppl.), 47-51.
Daley, C. M., Faseru, B., Nazir, N., Solomon, C., Greiner, K. A.,
Ahluwalia, J. S., & Choi, W. S. (2011). Influence of traditional
480  HEALTH PROMOTION PRACTICE / July 2016
This content downloaded from
168.176.5.118 on Mon, 15 Mar 2021 18:42:52 UTC
All use subject to https://about.jstor.org/terms
tobacco use on smoking cessation among American Indians.
Addiction, 106, 1003-1009. doi:10.1111/j.1360-0443.2011.03391.x
Dilley, J. A., Peterson, E., Hiratsuka, V. Y., & Rohde, K. (2013).
Discovering unique tobacco use patterns among Alaska Native
people. International Journal of Circumpolar Health, 72.
doi:10.3402/ijch.v72i0.21208
Driscoll, D. L., Hiratsuka, V., Johnston, J. M., Norman, S., Reilly,
K. M., Shaw, J., . . . Dillard, D. (2013). Process and outcomes of
patient-centered medical care with Alaska Native people at
Southcentral Foundation. Annals of Family Medicine, 11(Suppl.
1), S41-S49. doi:10.1370/afm.1474
Eby, D. K. (2007). Primary care at the Alaska Native Medical
Center: A fully deployed “new model” of primary care.
International Journal of Circumpolar Health, 66(Suppl. 1), 4-13.
Erwin, D. O., Trevino, M., Saad-Harfouche, F. G., Rodriguez, E.
M., Gage, E., & Jandorf, L. (2010). Contextualizing diversity and
culture within cancer control interventions for Latinas: Changing
interventions, not cultures. Social Science & Medicine, 71, 693-
701. doi:10.1016/j.socscimed.2010.05.005
Fenn, D. C., Beiergrohslein, M., & Ambrosio, J. (2007). Southcentral
Foundation tobacco cessation initiative. International Journal of
Circumpolar Health, 66(Suppl. 1), 23-28.
Filippi, M. K., Young, K. L., Nazir, N., Williams, C., Brown, T.,
Choi, W. S., . . . Daley, C. M. (2012). American Indian/Alaska
Native willingness to provide biological samples for research
purposes. Journal of Community Health, 37, 701-705. doi:10.1007/
s10900-011-9502-3
Glaser, B. G. (1965). The constant comparative method of qualita-
tive analysis. Social Problems, 12, 436-445.
Harding, A., Harper, B., Stone, D., O’Neill, C., Berger, P., Harris,
S., & Donatuto, J. (2012). Conducting research with tribal com-
munities: Sovereignty, ethics, and data-sharing issues.
Environmental Health Perspectives, 120, 6-10. doi:10.1289/
ehp.1103904
Hiratsuka, V., Brown, J., & Dillard, D. (2012). Views of biobanking
research among Alaska native people: The role of community
context. Progress in Community Health Partnerships, 6, 131-139.
doi:10.1353/cpr.2012.0025
Hodge, F. S. (2012). No meaningful apology for American Indian
unethical research abuses. Ethics & Behavior, 22, 431-444.
Holkup, P. A., Rodehorst, T. K., Wilhelm, S. L., Kuntz, S. W.,
Weinert, C., Stepans, M. B., . . . Hill, W. G. (2009). Negotiating
three worlds: Academia, nursing science, and tribal communities.
Journal of Transcultural Nursing, 20, 164-175. doi:10.1177/
1043659608325845
Hurt, R. D., Renner, C. C., Patten, C. A., Ebbert, J. O., Offord, K. P.,
Schroeder, D. R., . . . Moyer, T. P. (2005). Iqmik—a form of smoke-
less tobacco used by pregnant Alaska natives: Nicotine exposure
in their neonates. Journal of Maternal-Fetal & Neonatal Medicine,
17, 281-289.
Iwelunmor, J., Idris, O., Adelakun, A., & Airhihenbuwa, C. O.
(2010). Child malaria treatment decisions by mothers of children
less than five years of age attending an outpatient clinic in south-
west Nigeria: An application of the PEN-3 cultural model. Malaria
Journal, 9, 354. doi:10.1186/1475-2875-9-354
Iwelunmor, J., Newsome, V., & Airhihenbuwa, C. O. (2014).
Framing the impact of culture on health: A systematic review of
the PEN-3 cultural model and its application in public health
research and interventions. Ethnicity & Health, 19, 20-46. doi:10.
1080/13557858.2013.857768
Laveaux, D., & Christopher, S. (2009). Contextualizing CBPR: Key
principles of CBPR meet the Indigenous research context.
Pimatisiwin, 7(1), 1.
Lewis, J. P., & Boyd, K. (2011). Determined by the community:
CBPR in Alaska native communities building local control and
self-determination. Journal of Indigenous Research, 1(2), 1-23.
Nadeau, M., Blake, N., Poupart, J., Rhodes, K., & Forster, J. L.
(2012). Circles of Tobacco Wisdom: learning about traditional and
commercial tobacco with Native elders. American Journal of
Preventive Medicine, 43(5 Suppl. 3), S222-S228. doi:10.1016/j.
amepre.2012.08.003
Patten, C. A., Enoch, C., Renner, C. C., Offord, K. P., Nevak, C.,
Kelley, S. F., . . . Kaur, J. S. (2009). Focus groups of Alaska Native
adolescent tobacco users: Preferences for tobacco cessation inter-
ventions and barriers to participation. Health Education &
Behavior, 36, 711-723.
Patten, C. A., Windsor, R. A., Renner, C. C., Enoch, C., Hochreiter,
A., Nevak, C., . . . Brockman, T. (2010). Feasibility of a tobacco
cessation intervention for pregnant Alaska Native women.
Nicotine & Tobacco Research, 12(2), 79-87.
Renner, C. C., Enoch, C., Patten, C. A., Ebbert, J. O., Hurt, R. D.,
Moyer, T. P., & Provost, E. M. (2005). Iqmik: A form of smokeless
tobacco used among Alaska natives. American Journal of Health
Behavior, 29, 588-594. doi:10.5555/ajhb.2005.29.6.588
Scarinci, I. C., Bandura, L., Hidalgo, B., & Cherrington, A.
(2012). Development of a theory-based (PEN-3 and Health
Belief Model), culturally relevant intervention on cervical can-
cer prevention among Latina immigrants using intervention
mapping. Health Promotion Practice, 13(1), 29-40. doi:10.1177/
1524839910366416
Schnarch, B. (2004). Ownership, Control, Access, and Possession
(OCAP) or Self-Determination Applied to Research: A Critical
Analysis of Contemporary First Nations Research and Some
This content downloaded from
168.176.5.118 on Mon, 15 Mar 2021 18:42:52 UTC
All use subject to https://about.jstor.org/terms
Options for First Nations Communities. Journal of Aboriginal
Health, 1, 80-95.
Shore, N., Drew, E., Brazauskas, R., & Seifer, S. D. (2011).
Relationships Between Community-Based Processes for Research
Ethics Review and Institution-Based IRBs: A National Study.
Journal of Empirical Research on Human Research Ethics, 6(2),
13-21.
Street, R. L., Jr., Makoul, G., Arora, N. K., & Epstein, R. M. (2009).
How does communication heal? Pathways linking clinician-
patient communication to health outcomes. Patient Education
and Counseling, 74, 295-301.
U.S. Department of Health & Human Services. (1998). Tobacco
use among U.S. racial/ethnic minority groups—African
Americans, American Indians and Alaska Natives, Asian
Americans and Pacific Islanders, and Hispanics: A report of the
surgeon general (2nd ed.). Washington, DC: U.S. Government
Printing Office.
U.S. Public Health Service. (2008). Treating tobacco use and
dependence 2008 update. Retrieved from http://purl.access.gpo.
gov/GPO/LPS102957
Vasgird, D. (2007). Making research trustworthy for Native
Americans. Journal of Empirical Research on Human Research
Ethics, 2(1), 84-85. doi:10.1525/jer.2007.2.1.84
Vink, J. M., Willemsen, G., & Boomsma, D. I. (2005). Heritability
of smoking initiation and nicotine dependence. Behavior
Genetics, 35, 397-406. doi:10.1007/s10519-004-1327-8
Wassenaar, C. A., Dong, Q., Wei, Q., Amos, C. I., Spitz, M. R., &
Tyndale, R. F. (2011). Relationship between CYP2A6 and
CHRNA5-CHRNA3-CHRNB4 variation and smoking behaviors
and lung cancer risk. Journal of the National Cancer Institute,
103, 1342-1346.
Williams, M., Moneyham, L., Kempf, M. C., Chamot, E., &
Scarinci, I. (2015). Structural and sociocultural factors associated
with cervical cancer screening among HIV-infected African
American women in Alabama. AIDS Patient Care and STDs,
29(1), 13-19. doi:10.1089/apc.2014.0063
Hiratsuka et al. / APPLICATION OF THE PEN-3 MODEL  481