This document summarizes a study that explored young adults' perceptions of how social media influences their health behaviors related to diet and exercise. The study conducted focus groups and interviews with 34 young adults. It found that social media was perceived to both motivate and act as a barrier to exercise. Participants also felt that social media expanded their food choices through recipes and sharing food photos, but could also distract from making healthy choices. Many reported posting about exercise on social media. The study discussed these findings in the context of social ecological theory and how social media may impact individual health factors.

1. Computers in Human Behavior 45 (2015) 151–157
Contents lists available at ScienceDirect
Computers in Human Behavior
j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c
a t e / c o m p h u m b e h
#Gettinghealthy: The perceived influence of social media on
young
adult health behaviors
http://dx.doi.org/10.1016/j.chb.2014.12.013
0747-5632/� 2014 Elsevier Ltd. All rights reserved.
⇑ Corresponding author. Tel.: +1 (406) 994 3229.
E-mail addresses: [email protected] (J.M. Vaterlaus),
[email protected]
ksu.edu (E.V. Patten), [email protected] (C. Roche),
[email protected]
(J.A. Young).
1 Tel.: +1 (208) 861 0727.
2 Tel.: +1 (308) 865 8477.
J. Mitchell Vaterlaus a,⇑ , Emily V. Patten b,1, Cesia Roche c,
Jimmy A. Young d,2
a College of Education, Health and Human Development,
Department of Health and Human Development, Montana State
University, P.O. Box 173540, Bozeman, MT
59717-3540, United States
b College of Human Ecology, Department of Hospitality
Management and Dietetics, Kansas State University, 110 Justin
Hall, Manhattan, KS 66506-1404, United States
c College of Business and Technology, Department of Family

2. Studies and Interior Design, University of Nebraska Kearney,
Otto Olsen 205E, Kearney, NE 68849, United States
d College of Natural and Social Sciences, Department of Social
Work, University of Nebraska Kearney, 2022 Founders Hall,
Kearney, NE 68849, United States
a r t i c l e i n f o
Article history:
Available online 23 December 2014
Keywords:
Social media
Young adulthood
Diet
Exercise
Health
Social ecological theory
a b s t r a c t
Young adults (18–25 years old) spend a majority of their
waking hours with technology and young adult-
hood is an important developmental time period for establishing
lasting health behaviors. Considering
the relevance of technology and health during young adulthood
the current study explored young adults
(N = 34) perceptions of social media’s (e.g., social networking)
influence on their health behaviors (i.e.,
diet and exercise) using a social ecological framework. Data
was collected through eight focus groups
and four individual interviews. Three themes were identified
through phenomenological qualitative
analysis. Young adults perceived that technology could be both
a barrier and a motivator for exercise.
Social media was also credited with expanding food choices

3. through creating access to a variety of
recipes, providing a venue for showcasing the food young adults
eat or prepare, and distracting young
adults from making positive food choices. Participants also
reported that it is common to post statuses
or pictures relating to exercise practices on social media during
young adulthood. Young adults indicated
that these posts could be inspirational or misused, depending on
the context. Results are discussed in
terms of theory and preliminary implications.
� 2014 Elsevier Ltd. All rights reserved.
1. Introduction
Young adults (18–25 years old) spend more time with media
and technology daily than any other activity (Coyne, Padilla-
Walker, & Howard, 2013). Media and technology that facilitate
social interaction (i.e., social media) are preferred mediums
among
young adults (Xenos & Foot, 2008). The developmental time
period
of young adulthood is marked by transition (e.g., living arrange-
ments, college, work) and the development of some
independence
while maintaining some continued reliance on parents for a
variety
of resources (e.g., financial support, emotional support;
Aquilino,
2006; Arnett, 2000). With increased independence and
transitions,
young adulthood has been proposed to be an important time per-
iod for the development of lasting health behaviors (Nelson,
Story,
Larson, Neumark-Sztainer, & Lytle, 2008). A variety of factors
(e.g.,
individual, environmental) influence health behaviors and social

4. media may be an important factor in understanding young adult
health (Freeland-Graves & Nitzke, 2013). It is essential to
identify
the influence of technology use on health behaviors during
young
adulthood due to the potential salience of health behaviors and
fre-
quency of technology use during this time period of
development.
The current exploratory study was designed to begin to identify
the perceived connection between health behaviors (i.e., diet
and
exercise) and social media use among young adults.
1.1. Social media in young adulthood
New media and technology are viewed by young people as a
normal part of daily living (Brown & Bobkowski, 2011; Cupples
&
Thompson, 2010). It has been reported that young adults spend
between 11 and 12 h a day with technology and media (Alloy
Media, 2009; Kaiser Family Foundation., 2010). Young adults
have
a particular affinity for social media—or technologies that
facilitate
social interaction (Xenos & Foot, 2008). As of January 2014,
89% of
18–29 year olds report using social networking sites and 67%
access these sites on their cell phones (Pew Research Center,
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.013&domain=pdf
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5. mailto:[email protected]
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152 J.M. Vaterlaus et al. / Computers in Human Behavior 45
(2015) 151–157
2014). The social media landscape has expanded to include
several
different platforms for interaction and communication (Duggan
&
Smith, 2013). One of the most popular features afforded by
these
social platforms is photo sharing and 79% of 18–29 year olds
report
sharing photos they have taken online (Duggan, 2013). Table 1
provides a summary of some of the most popular social media
plat-
forms that are utilized by young adults. Facebook (84%)
continues
to be the most widely accessed social networking site, although
young adults also report accessing additional sites such as
Twitter
(53%), Instagram (37%), and Pinterest (27%) (Duggan & Smith,
2013). Additionally, 26% of young adults report using the
Snapchat
mobile app (Duggan, 2013). Considering the quantity of time
young adults spend with technology and the variety of social
media platforms available, it appears that social media has
become
a normative aspect of young adult life.
1.2. Young adult health behaviors
The Academy of Nutrition and Dietetics (Academy) advocates

6. for the total diet approach, which emphasizes that a health-
promoting lifestyle consists of varied and moderate intake of
nutrient-dense food, coupled with adequate physical activity
(Freeland-Graves & Nitzke, 2013). Consistent with the total diet
approach, our conceptualization of health behaviors included
both
diet and exercise. Young adulthood has been proposed to be a
risky
time period for the development of poor diet and exercise habits
(Nelson et al., 2008). The National College Health Assessment
(NCHA; American College Health Association, 2013) reported
that
58.7% of young adults (N = 123, 078; mean age = 22.82) eat
one
to two servings of fruits and vegetables per day and 56.6%
engage
in moderate-intensity cardio exercise between one and four
times
a week. This large scale health survey also asked students to
address a variety of contextual factors such as relationships,
aca-
demic performance, finances, etc., but does not include
questions
about technology or media use. This is surprising considering
the
amount of time young adults spend with technology.
1.3. Social ecological theory: Media and health
There are a variety of factors that influence health behaviors
and we propose that social media could be a relevant factor
contributing to a persons’ total diet. The social ecological
model
has been used to describe the complexity of how people make
the decisions to eat what they eat within concentric ecosystem
lev-

7. els (i.e., individual factors, environmental settings, sectors of
influ-
ence, and social and cultural norms and values; Freeland-Graves
&
Nitzke, 2013). Within the social ecological theory, individual
fac-
tors in making food choices include time availability,
convenience,
and psychosocial factors. The sector of influence level of the
Table 1
Descriptions of Select social media platforms.
Name of
platform
Brief description
Facebook Allows users to create a personal profile to share
selected personal in
accept friends with whom they wish to connect. Facebook
allows for
found on the internet
Twitter Allows users to create a brief profile with a photo.
Twitter allows use
updates referred to as Tweets. Twitter users can follow people
or org
Instagram This is a photo and video sharing app. Users can take
a picture and se
with their followers. Users develop their own profile and can
select t
updates
Pinterest This platform is an electronic pin board. Users create a
profile and ‘‘pin

8. form of social bookmarking where users can organize
information on
information
Snapchat A photo and video sharing app that allows users to
share with a speci
Snaps. Senders can decide how long (between 1 and 10 s) the
receive
ecological model includes the larger societal structures and
influ-
ences on food choices and exercise such as government, agricul-
ture, and industry. Media and technology, also at the sector of
influence level, has been credited as one factor that has led to a
shift in perceptions, attitudes, and beliefs about nutrition during
the last 50 years (Freeland-Graves & Nitzke, 2013). Social
scientists
have proposed that media and technology now have a more
direct
influence as they are a regular part of young peoples’
psychosocial
experience (McHale, Dotterer, & Kim, 2009). It is proposed that
media and technology are now a part of the individual factors
level
of the ecological system. Considering the relevancy of
environmen-
tal factors on health behaviors, it would be logical to
investigate
the relationship between young adult social media use and
health
behaviors among young adults.
1.4. Connecting social media to health behaviors
Media and technology (e.g., TV, movies, video games, Internet)
are conceptualized as sedentary activities that displace time for
physical activity and ultimately lead to increases in Body Mass

9. Index (BMI) among children and adolescents (Arora et al.,
2013;
Proctor et al., 2003). With technological convergence (i.e., the
abil-
ity to access several technologies from one device) many young
adults have access to social media on their cell phone and prefer
to carry their social network around with them at all times
(Brown & Bobkowski, 2011), which could be indicative of an
increase in sedentary behavior. Television viewing has also
been
investigated in association with food choices and portion sizes
(Blass et al., 2006; Cleland, Schmidt, Dwyer, & Venn, 2008).
Young
adult abdominal weight gain can be partially explained by the
foods and beverages consumed while watching TV (Cleland et
al.,
2008) and young adults are more likely to consume high-density
foods (e.g., pizza and macaroni and cheese) with less
moderation
while eating and viewing TV concurrently (Blass et al., 2006).
Like
TV, social media could serve as a distraction during eating.
How-
ever, unlike television social media allows for interaction with
oth-
ers through technology.
The interactive nature of social media may have a different
influence on young adult health behavior than non-interactive
technologies (e.g., TV, movies, music). Researchers have
identified
that social interaction can influence food choices and portions
among young adults (McFerran, Dahl, Fitzsimons, & Morales,
2010). For example, an experimental study concerning food
con-
sumption in social situations reported that all of the young adult

10. participants were likely to take more food than the consumer
before them, but the people who followed a thin consumer in a
food line took significantly less food when compared to people
who followed after an obese consumer (McFerran et al., 2010).
It
may be that social media use can be a distraction, like TV, for
Website
formation, interests, photos or videos. Users can find and
status updates, instant messaging, and posting content
www.facebook.com
rs to share photos, videos, and brief 140-character status
anizations to stay connected
www.twitter.com
lect different filter options in order to share their picture
o follow specific people/organizations to get photo/video
www.instagram.com
’’ (i.e., post) content from the internet to their board. It is a
their own board and follow other Pinterest users to share
www.pinterest.com
fied group of recipients. Sent messages are referred to as
r(s) can view the Snap before it is erased
www.snapchat.com
http://www.facebook.com
http://www.twitter.com
http://www.instagram.com

11. http://www.pinterest.com
http://www.snapchat.com
J.M. Vaterlaus et al. / Computers in Human Behavior 45 (2015)
151–157 153
moderate food intake, but the interactive nature of social media
may have a unique relationship with health behaviors. Food
con-
sumers now use social media to inform others about what they
eat through posts, restaurant reviews, recipes, and pictures
(Zimmer & Kaplan, 2014). Social media also affords the
opportunity
for users to control how they present themselves to their social
network (Zhao, Grasmuck, & Martin, 2008). Users can present
the
version of themselves that they hope for, rather than their actual
selves, which could potentially influence the content they post
relating to their health behaviors (e.g., I want people to think I
exercise and eat healthy so I ‘‘like’’ exercise and nutrition
pages
on Facebook).
Finally, social media could be a tool to learn about health
behaviors and seek support. Young adults have reported using
social media to seek health related social support from people
within their social network (Oh, Lauckner, Boehmer, Fewins-
Bliss,
& Li, 2013). Further, young adults have reported using the
internet
as a health information source (McKinley & Wright, 2014). The
internet has risen from an obscure nutrition resource in 1995
(3%
of respondents) to the third (40% of respondents) most utilized
nutrition information resource in 2011 behind television and
mag-

12. azines (Academy, 2011). With the ability to share information
via
social media it is a real possibility that social media has become
an important health information source on the internet (Rutsaert
et al., 2013). This does not mean that all the information about
diet
and exercise is accurate. Pseudo professionals, celebrities, and
the
population at large now can disseminate information about
health
behaviors (whether accurate, inaccurate, oversimplified, or
exag-
gerated) virally with social media outlets (Freeland-Graves &
Nitzke, 2013; Rutsaert et al., 2013).
1.5. Purpose of the current study
At present the relationship between social media use, diet, and
exercise in young adulthood is unclear. As such, we designed an
exploratory qualitative study to capture young adults’
perceptions
of the phenomenon. Young adult perceptions are important
because perceptions ‘‘help to influence how people think of
them-
selves and how others think of them’’ and can ultimately
influence
behavioral outcomes (Taylor, 2014, p. 52). Our aim was to give
voice and provide a rich description of young adults’ lived
experi-
ence with the phenomenon, and to generate further research
inter-
est on social media and health behaviors. The study was guided
by
the following research question:
What are the perceived influences of social media on young

13. adult health behaviors (i.e., diet and exercise)?
2. Methods
2.1. Design
A qualitative focus group approach was selected to ‘‘uncover
factors that influence opinions, behavior, or motivation’’
(Krueger
& Casey, 2000, p. 24) surrounding the perceived influence of
social
media on young adult health behaviors. Focus groups have been
shown to be effective in health (Neumark-Sztainer, Story, Perry,
& Casey, 1999) and social media (McLaughlin & Vitak, 2012)
research. To ensure saturation (i.e., themes become repetitive as
additional focus groups are implemented and by the later focus
groups no new information emerges; Krueger & Casey, 2000)
occurred, eight focus groups (m = 4.25 participants per group)
were
scheduled. In-depth semi-structured interviews were also
included
within this study. Using multiple approaches in qualitative
research increases the trustworthiness of the results (Vaterlaus
&
Higginbotham, 2011).
2.2. Sample
Young adult participants (N = 34) were recruited from five
courses at a midwestern university in the United States to
partici-
pate in a research study focused on social media use in young
adult
life. The mean age for male (n = 7) and female (n = 27)
participants
was 20.4 years old. All of the participants reported cell phone
own-
ership and 97.1% indicated that their phone was a ‘‘smart

14. phone’’.
Table 2 presents demographic information and selected health
and
social media practices of the sample.
2.3. Data collection and analysis
The project primarily utilized focus group methodology and was
approved by the university IRB. The instructors of five courses
agreed to allow student participation and one researcher
presented
the option and study protocol to each course. Students were
offered
extra credit to incentivize participation in one of eight focus
groups.
One researcher, with experience in group counseling skills,
facili-
tated the focus groups which included (a) an introduction and
explanation of informed consent, (b) participant completion of a
short questionnaire including questions relating to
demographics,
technology use, and health behaviors, and (c) 50–60 min
videotaped
semi-structured focus groups consisting of open-ended
questions
about social media use on daily life (i.e., relationships,
exercise,
and diet). Participants were specifically asked, ‘‘What, if any,
are
the influences of social media on your eating habits’’ and
‘‘What, if
any, are the influences of social media on your exercise
habits’’,
but participants also discussed health practices throughout the
focus groups. To protect participant confidentiality codes were
used
to pair participant responses with their questionnaire responses.

15. Additionally, four students (n = 2 male; n = 2 female)
volunteered
(no additional incentive) to participate in semi-structured, audio
recorded, 50–60 min interviews to gain a more in-depth
perspective
on social media and daily life.
Focus groups and individual interviews were transcribed verba-
tim, any identifiable information was deleted, and all
information
relating to health behaviors (i.e., exercise or diet) was extracted
to form the data set for this study. A phenomenological
qualitative
approach (van Manen, 1984) was used to capture young adults’
lived experience with social media and health behavior. A
human
development scholar and a dietetics scholar independently
immersed themselves in the data and highlighted (van Manen,
1984) commonalities. The two researchers met together to
discuss
the commonalities. Three themes were identified and the data
was
coded independently line-by-line (van Manen, 1984) resulting in
93% inter-coder agreement. Disagreements were resolved by
con-
sulting the data to ensure participant experience was accurately
presented. To increase the trustworthiness of the results a varia-
tion of member checking was employed (Vaterlaus, Beckert,
Tulane, & Bird, 2014). The results were sent to two of the focus
group participants and they were asked to review the
consistency
of the themes with their own experience and with their peers’
gen-
eral experience. Both indicated that the themes were represented
with their peers and their own experience with social media and
health behaviors.

16. 3. Results
The majority of participants (n = 32) perceived that social
media
has an influence on young adult health behaviors. Three themes
were identified using a phenomenological approach that articu-
lates the young adult lived experience with social media and
health behaviors. The themes included: (a) social media as a
moti-
vator and barrier to exercise, (b) the perceived connection
between
Table 2
Sample characteristics.
Participants
n %
Demographic characteristics
Ethnicity
Caucasian 28 82.4
Hispanic/Latino 6 17.6
Marital status
Single 30 88.2
Married/cohabiting 4 11.8
Living arrangement
On campus housing 11 32.4
Off campus housing 22 64.7
With parents 1 2.9

17. Participant BMI categorization
Under-
weight
Normal
weight
Overweight Obese
(n = 1) (n = 24) (n = 6) (n = 3)
Health and social media behaviors
Social media behavior
Average number of texts
sent per day
20 67 87 83
Average number of
Snapchats sent per day
0 13 18 20
Average number of
Instagram posts per week
0 2 3 0
Average amount of time
on Facebook per day
6.0 hrs 1.3 hrs 7.5 hrs 3.7 hrs
Diet

18. Average number of days
per week eat
2 ½-3 cups of vegetables 2.0 3.0 3.2 1.6
2 cups of fruit 4.0 3.0 3.0 1.3
Primary Source of meal
preparation
Cafeteria meal plan 33%
Self-preparation 100% 58% 83% 67%
Relative preparation 4% 17%
Eat out 4% 33%
Exercise
Average number of
exercise sessions per
week
0 3.2 3.5 3.0
Average length of exercise
time per session
0 min 40–50 min 40–50 min 20–30 min
Type of exercise*
Cardio 150% 83% 67%
Strength training 42% 7% 67%
Yoga 13% 33%
No exercise 100% 13% 2%
Note. The criteria from Center for Disease Control (CDC; 2011)
for identifying Body
Mass Index (BMI; BMI < 18.5 is underweight; BMI > 18.5 and

19. < 24.9 = normal;
BMI > 24.9 and < 29.9 = overweight; and, BMI > 30 = Obese)
was used.
* Case percentages (often exceeding 100%) are reported
because participants
indicated more than one type of exercise.
154 J.M. Vaterlaus et al. / Computers in Human Behavior 45
(2015) 151–157
food and social media, and (c) the perceptions of exercise
pictures
and posts online. Percentages of participants are included to
indi-
cate the prevalence of themes and subthemes. Participants were
only counted once in these percentages for each
theme/subtheme.
For example, a participant who participated in a focus group
and
individual interview were counted only once in the prevalence—
even if they talked about the theme more than once. The themes
are presented in order of prevalence.
3.1. Social media as a motivator and barrier to exercise
The majority of participants (97%) explained that social media,
like everything else, ‘‘has pros and cons.’’ Participants
perceived
that social media could both be a motivator and a barrier to
exercise in young adulthood. For example, a young adult
(female,
19) explained the ways that social media could influence her
exer-
cise habits as: ‘‘ (a) I don’t go exercise because I’m on
Facebook and
just being lazy or (b) I’m on Pinterest and I look at these cool

20. exer-
cises, and I’m like dude I’m gonna try this out.’’ Thirty-four
percent
of participants reported that technology was a both a motivator
and a barrier to exercise in young adulthood. In total, 50% of
partic-
ipants perceived that social media could motivate them and their
peers to exercise, while 47% perceived that social media was a
bar-
rier to exercise among young adults.
3.1.1. Motivator
Participants indicated that social media provides specific apps,
like ‘‘Nike + ’’ (see https://secure-nikeplus.nike.com/plus/) and
‘‘Map My Run’’ (see www.mapmyrun.com), they use to track
their
progress and increase accountability. They also acknowledged
that
social media platforms increase access to new exercises. Partici-
pants shared that they followed exercise pages or organizations
on Instagram, Pinterest, and Facebook to stay motivated. A
partic-
ipant (male, 19) declared, ‘‘I’m on Pinterest and I look at these
cool
exercises and I’m like, I’m going to try this out and then I
exercise
more.’’ Seeing other peoples’ accomplishments in
‘‘#transforma-
tiontuesday’’ (i.e., posting before and after weight loss
pictures)
posts, pictures of progress through participation in specific
exer-
cise programs (e.g., Crossfit; see www.crossfit.com), and
motiva-
tional quotes were also perceived to increase the personal desire

21. to exercise. A young adult (male, 22) explained:
You see a little quote or something like ‘‘what are you doing
with your life.’’ And you’re like hey I’m better than this I’m
not going to bother eating this tub of ice cream. I’m going to
go out there and run.
Finally, social media was perceived to be a motivator in its own
right because people are going to post pictures and people are
‘‘obviously going to want to look their best for everybody
they’re
sharing pictures with’’ (female, 22).
3.1.2. Barrier
Young adults indicated that social media could serve as a bar-
rier to exercise in terms of displacing exercise time, being
distract-
ing during exercise, and by providing inaccurate information
about
exercise. A participant (female, 21) confessed:
I was just going to look on Facebook just for a little while then
I
was going to go workout. Then I get enticed by something and
time flies by and then I’m like, ‘‘Oh it’s really late and I don’t
want to go to the gym anymore.’’ So I end up not going to the
gym. . . . [Social media] is a big part of our daily lives and
some
people just don’t realize how much it does consume our lives
and so sometimes the gym or exercise of any kind gets put on
the back burner.
Further, finding exercise information and tips online was also
described as a barrier because weak commitments are made to
actually exercising. For example, A (male, 22) described a

22. process
of finding good workout ideas on Pinterest and then:
. . .saying ‘‘oh that sounds great’’ but you continue looking
through the crap saying, ‘‘Oh I’m going to try this at some point
in my life.’’ The next day you do the same thing over and over
and you don’t ever act on it.
Young adults also described how social media was distracting
while exercising. For example, ‘‘When I’m at the gym and my
phone starts buzzing because someone messaged me or they
liked
something on Twitter. I’m like seriously leave me alone. This is
my
time to focus.’’ (male, 20). In addition to being distracting,
some of
https://secure-nikeplus.nike.com/plus/
http://www.mapmyrun.com
http://www.crossfit.com
J.M. Vaterlaus et al. / Computers in Human Behavior 45 (2015)
151–157 155
the advertisements or information may be misleading. A young
adult (male, 21) observed how one of his friends was misled by
a
‘‘get ripped quick’’ scheme. He stated:
[My friend] saw this ‘‘click here and get one free month of this
supplement’’ [social media post] and he ordered it and he
showed me. It was going to be absolutely terrible for him . . .
He was pretty excited and I ended up throwing it away because
it wasn’t healthy for him at all.
3.2. The perceived connection between food and social media

23. Participants (81%) talked about the connection between food
and Facebook, Twitter, Pinterest, Snapchat, and Instagram.
They
talked about this social media and food connection in three
distinct
ways. Participants (38%) reported that social media was
associated
with increased food choices. Social media was also perceived by
participants (28%) to be a venue to share pictures of their food
with
their social network. Finally, participants (32%) explained that
social media could be a source of distraction during meal times
and when making food choices.
3.2.1. Expanded food choices
Participants indicated that recipes are readily available on Pin-
terest, Facebook, and Twitter. A young adult (female, 21)
revealed
that social media:
. . . gives you more ideas to work with. I mean, let’s be honest,
we pretty much all get into our ‘eating habits’ and they may
not always be the best or they may be really boring. We eat
the same stuff so sometimes it’s like, ‘‘that sounds really good
I’m going to try it.’’ [Social media] may open this realm of
taste
that you never have experienced.
A young adult (male, 21) stated, ‘‘I actually use Twitter for
good
diets and eating habits so [Twitter] is beneficial for me.’’
Partici-
pants indicated that there were good opportunities for healthy
recipes on social media although they cautioned that the
majority

24. of recipes available were for ‘‘unhealthy foods,’’ ‘‘sweets,’’
and
‘‘desserts.’’ Social media was also credited with expanding
food
choices/recipes for specific diets like ‘‘paleo,’’ ‘‘vegan,’’ or for
specific ‘‘food allergies.’’
3.2.2. Showcasing food
Participants discussed that the practice of posting pictures of
food on social media was to either entice others to want to make
the food or to just showcase their own food preparation skills. A
participant (male, 20) indicated that on Instagram, ‘‘the big
hash-
tag they use is #foodporn. They want you to look at it, and be
like,
‘That looks delicious!’’’ Illustrating the other major reason for
post-
ing food a young adult (female, 21) disclosed, ‘‘I don’t like to
cook,
so it’s like ‘Oh, I outdid myself’ so I’m actually going to share
it
because it actually looks edible.’’ However, young adults
indicated
that posting pictures of food too frequently is irritating—‘‘I
don’t
want to deal with what someone’s eating every five minutes’’
(female, 21).
Young adults elucidated that viewing these posts could lead to
feeling hungry, eating, or restraint. A young adult (female, 21)
divulged, ‘‘People post pictures of food all the time and it
makes
me want to go eat. It makes me hungry when I’m not really
hungry.
It makes me eat when I shouldn’t.’’ A young adult (male, 21)

25. shared, ‘‘My parents post desserts on Facebook and I look at
them
and want to try them.’’ Finally, showing restraint after viewing
a
food post of chocolate cake, a participant (female, 21) said,
‘‘That
looks good, but it’s not like I’m going to go buy a chocolate
cake
because of that.’’
3.2.3. Distraction
Social media was perceived to be a distraction that could lead to
(a) disconnection during meal times and (b) making poor food
choices. Participants explained that now most people spend
their
meal times ‘‘on their cellphone’’ instead of talking to the other
peo-
ple who are also eating. This disconnection during meal times
was
evident to participants when eating at home and while eating at
restaurants. In addition to disconnection, participants explained
that social media could shape the food choices young adults
make.
A young adult (female, 19) indicated, ‘‘If you’re on the
computer
you probably eat more than if you paid attention to what you’re
eating. I know if I’m just doing stuff [on the computer] and I’m
eat-
ing chips or something—I’ll just keep eating them.’’ Another
partic-
ipant (female, 21) shared this example about her roommate:
My roommate didn’t have class yesterday and so she was just
like, ‘‘Oh I’m just going to get on Instagram and Facebook and
just kind of check some things out.’’ . . . She forgot to eat lunch
because she got in that zone where she wasn’t paying attention

26. to time well . . . So what did she do? She went and picked up
some fast food and . . . was up really late studying. When if she
wouldn’t have been on the social media so much she could have
been able to manage her time more wisely . . . she loves to cook
and she tries to eat healthy. So for her to go out and eat fast
food
just because she was on social media all day really hindered her
healthy routine of eating on time and eating healthier foods.
3.3. #Gettingswoll: Exercise selfies and posts
Participants (59%) explained that taking exercise selfies (i.e.,
pic-
tures of themselves pre/post/during exercise), posting statuses,
sending texts, or sending Snapchats regarding exercise is a
regular
practice facilitated by social media. Participants affirmed that
exer-
cise updates via social networking were appropriate for large
accomplishments—losing a significant amount of weight or just
beginning a lifestyle that includes exercise. Collectively
participants
agreed that it was inspirational and motivational to see a person
post
a picture when they have lost a lot of weight. For example, a
partic-
ipant (male, 19) explained, ‘‘I have a friend who lost a lot of
weight
and it was cool, inspiring. He had never [posted a picture
before]—
His first one and I’m like that’s awesome. Some people do it to
get
attention.’’ Another participant (female, 20) added that she
waited
until she lost 80 pounds before she posted a picture on social
media.

27. When people frequently posted about working out or exercise
selfies this was perceived as a form of digital showboating or
brag-
ging that was annoying. In some instances participants felt like
the
person posting intended the viewers in their social network to
feel
shame about their own bodies. A (female, 20) lamented, ‘‘It’s
like
they post a pic ‘still really fat, trying to lose weight’ and their
mus-
cles are ripped and they got bulging biceps and you’re like
where’s
the fat?’’ Similarly another participant explained (male, 19):
It’s kind of more irritating sometimes when somebody will
Facebook, Tweet, or send a Snapchat or any of that stuff like,
‘‘Oh just at the gym’’ or ‘‘#gettingswoll’ [i.e., getting swollen]
it’s just annoying. I could understand if that was your first time
stepping foot in a gym and not knowing what to do was excit-
ing. Yeah, take a picture and send it to me because I’d like to
know. But you know where you go five or six times a week,
we already assume that for an hour a day you’re at the gym—
you don’t need to post about it.
People who frequently posted exercise posts and selfies were
thought to be ‘‘seeking attention’’ or looking for an ‘‘ego
boost.’’
One participant (male, 22) revealed why he did not post
exercise
selfies:
156 J.M. Vaterlaus et al. / Computers in Human Behavior 45
(2015) 151–157

28. Listen dude you’re posting pictures of yourself and you’re huge.
Your friend that feels they’re a little overweight and sees the
picture and they’re like, ‘‘dang man that’s really hard to get
to.’’ Instead post something like ‘‘if anybody needs a workout
buddy hit me up.’’ You know? Instead of posting a picture to
bum someone out.
4. Discussion
Young adulthood is a developmental time period marked by
transition (e.g., living arrangements, college, work) and large
quantities of time spent with media and technology (Arnett,
2000; Coyne et al., 2013). Because of the transitions during this
time period, young adulthood is a recommended area of study in
terms of physical health (Nelson et al., 2008). The aim of the
cur-
rent study was to identify the perceived influence of social
media
use on young adult health behaviors (i.e., diet and exercise).
The
majority of young adults in this study perceived that social
media
use does have an influence on young adult health behaviors.
Find-
ings from this study provide support for the social ecological
model—indicating that several factors, including social media,
can have an influence on health behaviors within the total diet
approach (Freeland-Graves & Nitzke, 2013). Results are
discussed
in terms of increased food choices, self-presentation, and how
social media is perceived to be a motivator or barrier to health
behaviors among young adults.
4.1. Food choices and social media
Consistent with previous research, young adults perceived that
social media serves as a platform to share and receive

29. information
about food (Zimmer & Kaplan, 2014). Participants reported that
their food choices were expanded through recipes that were
read-
ily available on social media platforms and that social media
could
assist people in varying meal plans. The Academy of Nutrition
and
Dietetics (2011) reported that the internet has become a top
source
for nutrition information and participants in this study
perceived
that social media specifically provided information about
specific
diets and eating habits. Participant responses provide additional
support for the theoretical proposition that social media is now
integrated into the individual factors level of the social
ecological
model (McHale et al., 2009) and that social media is perceived
to
have an influence on young adult food choices. Consistent with
social ecological theory (Freeland-Graves & Nitzke, 2013),
partici-
pants talked about how time spent (individual factors level)
with
social media could lead to distraction. This distraction could
lead
to eating immoderate food portions or selecting low nutrient
based
food items that are quick to consume because of time wasted on
social media. This finding is consistent with previous research
on
young adults’ food consumption during TV viewing (Blass et
al.,
2006). Also, food posts by participants’ friends in their social
net-

30. work (psychosocial influence at the individual factors level)
was
perceived to influence them to eat food when they were not hun-
gry, have the desire to prepare the food they see in the post, or
declare restraint and not allow the picture to influence their
food
choices. Consistent with McFerran et al. (2010), this provides
some
indication that social influences (digitally in this case) can
influ-
ence young adult diet practices.
4.2. Self-presentation
Social media provides a digital platform for users to present the
version of themselves that they want their social network to see
(Zhao et al., 2008). This phenomenon is referred to as a form of
self-presentation. Young adults reported that self-presentation
on
social media includes diet and exercise lifestyles. Participants
indi-
cated that social media could be used to showcase their ability
to
prepare food—presenting themselves as capable in the kitchen.
Pic-
tures and posts related to exercise practices were also seen to
shape a young adults’ personal brand on social media. It has
been
proposed that a youth culture has emerged around new technolo-
gies that is invisible to adults (Vaterlaus & Tulane, in press;
Oksman & Turtiainen, 2004). Participants’ responses provided
sup-
port for this proposition describing unwritten rules and mores
relating to posting health information. Young adults indicated
that
posting a weight loss picture was appropriate and applauded

31. when
a person lost a significant amount of weight. However, frequent
exercise or food posts were seen to be annoying attention
seeking
behaviors. Some participants suggested that some of these posts
could lead to body shame in viewers when pictures of fit people
had captions declaring they needed to lose more weight (when
they were in fact physically fit) or if the post’s creator
insinuated
that becoming exceptionally fit is an easy process.
4.3. Social media: A double-edge sword
Media and technology have largely been associated with nega-
tive health outcomes because of their sedentary and distracting
nature (Arora et al., 2013; Blass et al., 2006; Cleland et al.,
2008;
Proctor et al., 2003). Little is known about how social media
specif-
ically influences health outcomes. Participants did acknowledge
that social media could serve as a distraction from face-to-face
human interaction while eating, displace exercise time, and lead
to poor food/diet choices (e.g., missing meals, eating unhealthy
foods in large quantities). Also, some participants indicated that
there was inaccurate health information and products available
via social networking. In contrast, young adults also shared that
social media could be a motivator for positive health behaviors
and a venue to increase food choices. Social media was credited
with providing apps that increased exercise accountability,
infor-
mational pages that provided exercise and nutrition advice, and
inspirational quotes that were perceived to motivate people to
exercise. There is still much to be learned about the positive
and
negative influences of social media on health behaviors. Future
research should continue to explore the potential benefits and
challenges associated with social media in terms of young adult

32. health behaviors.
5. Preliminary Implications
Although considered preliminary, implications from this study
include that social media is a ripe and informal venue for
dissem-
inating health information to young adults. Evaluations of
formal
health interventions (e.g., self-directed weight loss program
hosted
on social media, nutrition educational curriculum offered
entirely
through social media) implemented on social media have been
shown to only have small participation rates and small benefits
(Williams, Hamm, Shulhan, Vandermeer, & Hartling, 2014). A
more
informal approach (i.e., not a prescribed curriculum or program)
to
using social media to promote health may reach more young
adults. An informal approach may involve health professionals
connecting with young adults in their community or
organization
through a variety of social media platforms—posting short
motiva-
tional quotes or memes (potentially focused on the total diet
approach), pinning or posting recipes, and posting or retweeting
accurate exercise information. Empirical evaluation the
effective-
ness of informal social media health promotion with young
adults
is needed.
Additionally, the youth culture that surrounds new technology
warrants more research attention. This line of research may lead

33. J.M. Vaterlaus et al. / Computers in Human Behavior 45 (2015)
151–157 157
social and health practitioners to better acculturate into this
youth
culture, which could lead to a better understanding in how to
nav-
igate and implement effective social media interventions for
young
adults. Finally, it is not surprising that results from this study
include both social and health implications. This study reaffirms
the importance of interdisciplinary studies within the social and
health sciences and the value of implementing a social
ecological
framework in human development research.
6. Limitations and conclusions
This study was not without limitations. As an exploratory study
a purposive sampling procedure was appropriate, but this limits
the generalizability of the results. The sample included young
adults enrolled in higher education from one region in the
United
States and results may vary with young adults from other
regions
and different educational/career aspirations. The sample was
also
primarily Caucasian. Future research should attempt to replicate
and extend these results with more diverse samples and with
mixed-method research designs. Despite the limitations, this
study
answers the call to conduct more research on factors influencing
health during young adulthood (Nelson et al., 2008). The study
also
gives voice to young adults’ own lived experiences—serving as
an
important step forward in understanding the connection between

34. social media use and young adult health behaviors.
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http://purl.umn.edu/173076
http://purl.umn.edu/173076#Gettinghealthy: The perceived
influence of social media on young adult health behaviors1

43. Introduction1.1 Social media in young adulthood1.2 Young
adult health behaviors1.3 Social ecological theory: Media and
health1.4 Connecting social media to health behaviors1.5
Purpose of the current study2 Methods2.1 Design2.2 Sample2.3
Data collection and analysis3 Results3.1 Social media as a
motivator and barrier to exercise3.1.1 Motivator3.1.2 Barrier3.2
The perceived connection between food and social media3.2.1
Expanded food choices3.2.2 Showcasing food3.2.3
Distraction3.3 #Gettingswoll: Exercise selfies and posts4
Discussion4.1 Food choices and social media4.2 Self-
presentation4.3 Social media: A double-edge sword5
Preliminary Implications6 Limitations and
conclusionsReferences
Social Support in Smoking Cessation
Among Black Women in Chicago Public Housing
LORETTA P. LACEY, DrPH, RN
CLARA MANFREDI, PhD
GEORGE BALCH, PhD
RICHARD B. WARNECKE, PhD
KAREN ALLEN, RN, PhD
CONSTANCE EDWARDS, RN, MS
Five of the authors are with the University of Illinois at
Chicago. Dr. Lacey is Associate Professor of Community
Health Sciences, School of Public Health, and Associate Profes-
sor of Public Health Nursing, College of Nursing; Dr. Manfredi
is Associate Director of Special Populations Research, Preven-
tion Research Center; Dr. Balch is visiting Associate Professor
of Marketing; Dr. Warnecke is Director, Survey Research
Laboratory, and Professor of Sociology and of Epidemiology
and Biometry; and Ms. Edwards is a doctoral candidate in the
School of Public Health. Dr. Allen is Assistant Professor,

44. School of Nursing, University of Maryland.
This research was funded by National Cancer Institute,
Cancer Control Science Program Project CA42760.
Tearsheets requests to Dr. Loretta Lacey, Community Health
Sciences, School of Public Health, University of Illinois at
Chicago, 2035 West Taylor St., (M/C 923), Chicago, IL 60612,
telephone 312-996-8578.
Synopsis....................................
To accomplish significant reductions in smoking
by the year 2000, special populations with relatively
low rates of smoking cessation must be reached
and helped to quit smoking. These populations are
most often groups in which traditional approaches
to smoking cessation have not been successful.
Focus groups were conducted with black women
who were residents of Chicago public housing
developments. The purposes were to assess factors
related to smoking and the women's willingness to
participate in cessation programs.
The findings reveal several barriers to smoking
cessation. These barriers are linked to the difficult
daily existence and environment of these women
and to a lack of social support that would help
them to achieve smoking cessation. The barriers
include (a) managing their lives in highly stressful
environments, (b) major isolation within these envi-
ronments, (c) smoking as a pleasure attainable with
very limited financial resources, (d) perceived mini-
mal health risks of smoking, (e) commonality of

45. smoking in their communities, (f) scarcity of infor-
mation about the process of cessation available to
them, and (g) belief that all they need is the
determination to quit on their own.
The women emphasized that smoking cessation
would be more relevant to them if part of broader
social support efforts geared to improve their lives.
The public health system may need to consider
such strategies to engage this group of women.
IN THE QUEST for a smoke-free society by the year
2000, some segments of the U.S. population lag
behind. For example, smoking prevalence rates
among young women with no more than high
school education and low income are high, while
smoking is declining in the total population (1-3).
Smoking is more prevalent among black than white
women because blacks have not stopped smoking
as rapidly as whites (1-4). Existing health promo-
tion programs that incorporate cessation have not
attracted the same participation or achieved the
same success among black women with low socio-
economic status (SES) as they have among black
and white women whose incomes are higher (5,6).
Additionally, participation in group efforts among
members of this population has been problematic
(7). Clearly, programs tailored to this segment of
the population are needed.
To attract greater participation from this group
of smokers, these programs must have a broader
focus than cessation alone. Boyd-Franklin (8) and
Trotman and Gallagher (9) document the benefits
of social support groups for black women based on

46. the sharing of their common experience and their
willingness to exchange emotional, spiritual, and
social assistance. Social support groups may be
especially important for low-SES urban black
women because they tend to experience a type of
isolation that creates fear and stress and distrust of
their environment. These factors limit their chances
May-June 1993, Vol. 108, No. 3 387
to build or join social networks and foster depen-
dence on smoking to reduce loneliness, reduce
stress, and provide affordable pleasure.
This paper reports formative research toward a
smoking cessation program that is socially support-
based and tailored to the needs of low-SES black
women. The focus groups that we describe were
originally designed to assess factors related to
smoking cessation and participation in such pro-
grams. However, as the groups progressed, it
became clear that there are powerful environmental
factors related to smoking that inhibit participation
in the kinds of programs currently offered.
We began to discover how the social environ-
ment of these women, particularly their social
isolation and limited sources of social support, is
inextricably linked to their smoking. It became
clear that successful cessation programs must mobi-
lize social support that will provide ways of coping
with these environmental factors to enhance cessa-
tion. Cessation programs that address these larger
issues will be more effective.

47. Background
Investigation of the factors associated with
smoking among low-SES black women was
prompted by the outcomes of an intervention that
proved satisfactory for the general Chicago popula-
tion but was less effective for low-SES black
women who are residents of Chicago public hous-
ing developments. The original study (7) used a
self-help manual,"Freedom From Smoking in 20
Days," and a series of televised segments on the
local evening news that followed the contents of
the manual. A supplement to the main intervention
was introduced in public housing developments.
This supplemental intervention was implemented by
lay health educators, who conducted a series of
specially designed classes on smoking cessation for
women 18-39 years old living in the housing
developments. The lay health educators had two
main tasks: to promote viewing of the televised
program and to elicit participation in the local
smoking cessation classes that were part of the
intervention (10).
More than 600 residents, who were canvassed
door-to-door in the housing developments, ex-
pressed interest in a smoking cessation program,
and more than 200 preregistered. However, main-
taining continuous participation in the smoking
cessation classes was problematic, and the number
of actual participants was less than half that of
those who preregistered.
We examined data from our baseline sample of
residents in housing developments not selected for

48. the intervention with data from a sample of the
general population of female smokers in the Chi-
cago metropolitan statistical area matched by age
and divided into two groups, one black and one
white. Based on this analysis, those in the public
housing sample had less interest in quitting or
desire to quit and were less likely to have made
plans to quit compared with other black or white
female smokers in the general population study.
Moreover, when we analyzed in detail the responses
of women in the housing developments, it was
evident that they did not share with other black
women or with white women the same understand-
ings about the relationship between smoking and
risk of disease, especially cancer, and did not see
how risks made smoking less desirable. On the
other hand, it was unclear from the results exactly
what value smoking held for these women (11).
How can this analysis and the results of the
original study be employed to design a more
effective program for women residents of public
housing? To address this task, we used qualitative
methods to help us understand the role of smoking
in the lives of these women and how best to deliver'
a cessation program relevant to these women.
Method
Marketing researchers commonly use focus
groups to provide data about how people think,
speak, act, and feel with respect to products,
services, and marketing communications (12-14).
Focus groups are used to identify issues important
to respondents in language that the respondents
use. Often, focus groups raise important issues that

49. researchers had anticipated; in other situations, the
results expand the data and generate new insights
and hypotheses about motivations, needs, symbols,
behavior, and meanings.
Recently, preventive health researchers have been
using focus groups to develop new interventions
(15-17). Schechter and coworkers (18), for exam-
ple, used focus groups to develop mammography
promotion messages. They- were used in Eckert's
research (19) to provide feedback on a smoking
cessation program among black adults.
We conducted eight focus groups with black
women residents from three Chicago public hous-
ing developments that were not among the inter-
vention sites for the original study. These women
had sociodemographic characteristics similar to
those of the women in the intervention sites.
388 Public Health Report
Specifically, our survey data revealed that 42 per-
cent of the women in public housing had not
completed high school, 66 percent were single
parents, and all had annual household incomes of
less than $13,000. By age 17, 68 percent had
initiated smoking. Just over half (51 percent)
smoked more than 10 cigarettes daily, and 96
percent smoked mentholated cigarettes. No or weak
desire to quit smoking was reported by 54 percent
(11).
Each group session had six to eight participants

50. and lasted about 2 hours. Discussion focused on
participants' daily activities, stresses and pleasures,
social environment, beliefs about smoking and
health, and smoking and health behavior. The
discussions followed a structured format to identify
perceived benefits of smoking, barriers to cessa-
tion, and receptivity to various cessation ap-
proaches.
To ensure reliability of the findings, we used
three different moderators (two black and one
white), multiple observers, and immediate postses-
sion debriefings. Observers wrote summaries of
each session. In addition, audiotapes and video-
tapes were made of each session, and transcripts of
the audiotapes were prepared and compared against
each videotape for accuracy and completeness.
Finally, all themes which emerged in the summaries
were cross-checked against the tapes and transcripts
for counter evidence.
Findings
Our synthesis of the sessions revealed a consis-
tent theme of distinct barriers to smoking cessation
that related to life circumstances and social envi-
ronments of the women. Their environments as
viewed through comments in the focus groups were
highly stressful. Smoking seemed to provide them
with relief and comfort.
Barriers to smoking cessation. Our synthesis of the
content of the group discussions indicated seven
barriers to the participants' cessation: (a) the
problems of managing their lives in a highly stress-
ful environment, (b) their isolation and the limited

51. support systems within these environments, (c) the
availability of smoking as an attainable pleasure in
a milieu with very limited resources for pleasure,
(d) perceived minimal health risks of smoking, (e)
the commonality of smoking, (f) the scarce-to-
nonexistent information about how to stop smok-
ing, and (g) the belief that all they need is determi-
nation to quit on their own.
All of these barriers followed from social isola-
tion and lack of support. In fact, we observed that
these women were most motivated to quit when
they were doing well, that is, working, attending
school, and receiving positive support. When their
lives left them little support or made them feel less
valued, they wanted to smoke. These general feel-
ings, however, can best be described when orga-
nized around the barriers.
Managing in a highly stressful environment. A
consistent theme among the women in the focus
groups was that smoking helps them to manage the
overwhelming pressures in their lives and to stay
calm. In this context, they believed smoking of-
fered strength for coping with the harsh realities of
their life situations in communities that presented
immediate and constant dangers to them and their
families. These communities were unclean, had
substandard housing, and offered few resources.
Life there was plagued by violence and crime, often
related to drug use. Although all smokers tend to
emphasize the stress-management utilities of smok-
ing as reasons for not quitting, the magnitude and
nature of stressors in these communities gave stress
a unique dimension. For example, one participant
described vividly the extreme stress encountered

52. daily in trying to get her daughter onto the school
bus:
My daughter use to have to get on the
[school] bus. She had to walk down the stairs,
stepping over the dope fiends and the junkies.
And one day she walked downstairs, this guy
was laying in the hallway with a needle in his
neck scaring her. She ran out to the bus, she
fell down, she missed the bus, she missed a
couple of days of school. I got to hear from
the school [about her absence] you know it's
bad.
Smoking was believed to bring some control
when the women faced so many situations over
which they had minimal control. Another partici-
May-June 1993, Vol. 108, No. 3 389
pant related the lack of control about the very
basic issues of survival as she described an encoun-
ter with the bureaucracy at the local welfare office
and her response:
To top it off, Public Aid mess me up. [She
was sent to the wrong office.] . . . I got there
late, and asked the gentleman, "Are you go-
ing to call my name back now?" He said,
"You have to wait." So they put down "no
show," then they sent me a letter decreasing
me for 3 months. Three months! ... I
smoked a lot on that day, do you hear me?

53. It was clear from watching the members of the
group that "lighting up" was a natural, norma-
tively accepted response to situations of this type.
They smoked to control their reactions to uncon-
trollable events.
Isolation and limited support systems. The struc-
ture of these communities promoted isolation. All
were located in racially and economically segre-
gated areas of the city. Some of these women lived
in housing developments considered the poorest
communities in the nation. One housing complex
was almost at the city limits, near a dump site.
Most of the high-rise buildings had poorly func-
tioning elevators and unsafe stairways, which lim-
ited movement outside of the home except for
necessary activities. General fear for personal
safety enhanced the physical and social isolation.
Women in the groups believed that development of
relationships and contacts beyond the immediate
family were risky. Opportunities to establish close
friendship networks were limited by the suspicion
that relationships with persons outside the house-
hold might create additional problems in their lives.
A recurring comment was that attempts to have
relationships outside of their immediate families
brought what was frequently described as confu-
sion into their lives. A participant who lived in a
high-rise development described why she limited
outside contact to her family: "I'm not visiting
too much-I'm a house person. There's too much
going on down there in the streets."
Families were the most trusted source of support.
For these women, family seemed focused on chil-
dren, sisters, and mothers. But still, many of the

54. participants described intense loneliness. One
woman, age 23, who smoked three packs of
cigarettes per day, had this vivid description of her
isolation:
I might be depressed or whatever and I don't
have anybody to talk to and my baby . . .
he'll be in his playpen. I'll just talk to him
and tell him a bit of my problems. He'll just
look at me, like mama I know what you are
going through or, you know . .. I just sit out
there and pour all my problems out to my
baby and sometimes I feel better.
One element frequently missing in the lives of
many of these women seemed to be the support
that can come from a male partner. A stable
relationship with a partner-whether or not he is
the spouse-means one can share problems, receive
emotional support, and in some cases, can rely on
someone to defend one's safety. But merely having
a partner was not enough to reduce the overwhelm-
ing stress caused by these women's environments.
Smoking as an attainable pleasure. Lack of
financial resources and physical and social isolation
limited access to sources of pleasure. Many pre-
fered to forego material pleasures for themselves to
provide the basic needs for their families. One
participant described her pleasure with smoking in
this context:
I have a lot of pressure on me. [She works,
takes care of an aging mother, has children,
and tries to keep the house together.] ... I
don't have time for me . .. so the only time I

55. have is when I take a cigarette out of the
pack and fire it. Cause that's the quickest
thing you can do, you know, something that
you want to do for yourself.
These women perceived smoking 'as a legal,
harmless pleasure, attainable for a relatively small
investment. The perceived alternatives were drugs,
alcohol abuse, or losing self-control. As one partic-
ipant remarked,
I'm going to have to stop smoking because I
really can't afford it but I've got to do some-
thing . . . I'd rather smoke than go there and
shoot some drugs or smoke a pipe or some-
thing like that.
Perceived minimal health risks of smoking. Al-
though these women tended to agree about the
negative effects of smoking on the health of their
children, they seemed less convinced about the
harmful health effects of cigarette smoking on
themselves or other adults. They felt that cigarette
390 Public Health Reports
smoking, in general, was not good, but they
expressed doubts about a specific link, for exam-
ple, between cancer and smoking. Few mentioned
cancer as a health concern for themselves or their
families.
Furthermore, they believed that the cancer that
they have seen among their family members and

56. other acquaintances was due to many other causes
than smoking. In fact, they were adamant that
medical scientists do not know the cause of cancer.
Balshem (20) has recently described similar findings
among a white working-class population. The
women in Balshem's focus groups also expressed
such fatalistic beliefs as "everything causes cancer"
and "once it occurs, there is little that medical
practitioners can do to control its course."
Surprisingly, even the actual presence of more
urgent health problems that smoking aggravates did
not deter these women. Several women had chronic
pulmonary disease (asthma, emphysema), heart dis-
ease, or kidney disease, but they continued to
smoke apparently unaware or unaccepting of a
possible relationship between smoking and these
health problems. Where they perceived possible
environmental effects, they attributed them to haz-
ards in their environments. These attributions had
a basis in reality, since some lived in housing
developments near waste dump sites, and all lived
in areas highly polluted with dust and dirt. They
emphasized this situation through their description
of their constant need to clean dirt from surfaces in
their homes.
Commonality of smoking. Another barrier to
cessation was the commonality of smoking in these
women's social environments. A consistent theme
throughout the groups was the belief that most
adults smoke. These women believed that more
than 75 percent of adults in their communities
smoked cigarettes. They thought that the rate in
the general population was the same.
When informed that smoking is decreasing and

57. that less than 30 percent of the general adult
population smokes, many of these women ex-
pressed disbelief. They seemed not to see smoking
in the same negative context that it increasingly
appears elsewhere. The actual prevalence within
their own social groups made it difficult to avoid
smokers or smoking situations and made their
perceptions accurate for their effective environ-
ment.
Scarce information about how to stop smoking.
Electronic media were a major source of health
information often cited by the women with whom
we spoke. This observation is consistent with our
1987 baseline data and has been reported by others
working with similar groups (21,22). When asked if
they knew where they could go or methods they
could use to help them stop smoking, nearly all
reported no knowledge about such resources. The
consensus was that the only way to quit smoking
was to do it on their own, "cold turkey."
Another theme emerging from this discussion
was that their sources of health information-
electronic media-provided little guidance about
smoking cessation. Although there were frequent
references to smoking-related issues on television,
the reports did not offer advice about or direction
for smoking cessation except for the infrequent
programs such as those offered in this study.
After tracking media references for 2 years, we
found very little in any of the media about
cessation. In our continuing work, we have found

58. that these women may be told often by their health
care providers to quit, but these recommendations
do not include clear guidance on how to quit.
Hence, there is minimal concrete direction to assist
them.
Determination to quit without help. Because of a
lack of specific guidance and information about the
cessation process and because of social isolation,
there was little awareness of the process and of the
fact that many smokers relapse and have to make
several attempts before successfully quitting smok-
ing. The lack of exposure to those who have tried
to quit reinforced the beliefs that only self-
determination leads to smoking cessation and that
those who quit must exert Herculean efforts. Per-
vasive smoking in the environment, the absence of
social support, and the likely absence of specific
constructive assistance should these women want to
quit reinforced their perceptions about the high
cost of trying. Besides, their reality was always to
be self-reliant; to be dependent or in need of
supportive help suggested vulnerability to their
May-June 1993, Vol. 108, No. 3 391
environment. Apparently, this ethos extended to
many areas of their lives.
The operative belief was that a woman must be
in control of herself to stop smoking, much as she
needed control to survive at all. Impersonal sources
of support in which she had little control were not
compatible with this belief structure. For example,

59. one woman recounted her failure to stop smoking.
She was among those who had seen a quit-smoking
manual at one of the local discount stores. When
asked if she thought a manual would work, she
replied,
No, if you haven't got the will power, it's not
going to work. You are just spending your
money on nothing. I look at it as if they are
taking my money. Because I'm not going to
go along with the program [because she does
not want to quit smoking] . . . if you really
want to stop smoking you don't need a man-
ual.
Others echoed from around the room, "It would
not work because they don't want to quit."
Social support. Smoking cessation in the face of all
of these barriers requires help and perseverance,
but the help must come from known and trusted
sources if it is to be accepted. Traditional smoking
cessation programs and the support from them
seemed not to be effective even when motivation to
quit is present.
Given these observations, it was surprising to
observe during these sessions a consistent pattern
of spontaneous formation of group support among
the women as they discussed their experiences and
frustration with everyday living. Most of these
women did not know each other before the group
sessions, yet they were remarkably accepting of
each other and openly shared experiences and the
accompanying sorrow, worry, and concerns. These
exchanges generated supportive and empathic un-

60. derstanding that obviously reflected common expe-
rience and resulted in warm, nonjudgmental, and
accepting interaction. As they shared personal sor-
rows, disappointments, joys (especially about their
children), and hopes during the limited session
time, each woman was accepted as having worth,
human dignity, and full membership in the group.
Some examples illustrate the empathic atmo-
sphere that emerged in each group. One young
woman had just been released from the county
correctional facility and shared her fear and sad-
ness about what led to her arrest and the possibility
of further incarceration:
I was scared because I never had a record be-
fore. I was never in trouble. And I've been
going to court since last year. They were get-
ting ready to give me 6 years, and they were
going to send me to Dwight [a State women's
correctional facility].
She related that her incarceration followed a
drug offense in which she had been both a user and
pusher. Her comments revealed a trust in the
members of the group, who had just discussed their
fears of and anger about pushers in their communi-
ties. The trust was well founded: when she con-
fessed to being one of those whom they had just
castigated, the response was nonjudgmental, warm,
and filled with expressions of relief that she did not
have to be incarcerated longer.
In another group, a woman said that she always
felt left out, as if she could not do anything right.

61. She had once prepared a Tupperware party and no
one came. She felt rejected by people in general,
and she did not know if group sessions (for
smoking cessation) would work for her. At that
point, a member of the session who had been
purposely reticent and almost hostile in her interac-
tions with the group said, "Well, you are accepted
here." Others agreed. The apparent need and
desire these women have to share their experiences
in an empathic but neutral setting may provide a
basis for interventions that might include smoking
cessation as a component.
Applying support to smoking cessation. Others
who have studied groups with black women have
reported the value of organizing the groups for so-
cial support (8,9). Participants in our focus groups
expressed enthusiasm about forming groups that
might help them to stop smoking. They immedi-
ately took ownership of the idea, providing several
valuable suggestions: (a) groups should be multi-
purpose, allowing for other important needs to be
met; (b) they do not need a professional leader,
since the direction of the discussion should come
from them; (c) organizers should be former smok-
ers; and (d) most of all, they wanted the group to
be a mechanism for them to give and receive emo-
tional and social assistance.
The group appeared to be seen as a potential
means of reducing the loneliness and isolation
experienced in their communities. These groups
were perceived as a neutral and safe environment,
392 Public Heafth Repors

62. not unlike that found in therapy groups; the group
was also seen as a potential social encounter, as
recreation. The women saw these groups as provid-
ing an opportunity for release from family obliga-
tions, such as the constant care of their children.
Finally, the group was seen as a way to learn about
life concerns from family- and household-related
tasks to job training. In each group, there was
considerable discussion about their desire and
strong need for employment. If the support serves
as a means of self-enhancement and esteem build-
ing, factors which they often associated with peri-
ods when they had stopped smoking, it may lead to
cessation.
The possibility of smoking cessation occurring
within groups that are formed to provide social
support is promising. These groups may offer the
help needed to attempt behavioral change. These
participants mentioned a variety of locales and
sites, some within their communities, in such places
as community centers and their homes. Churches,
which are often mentioned by health professionals
as promising places, were not mentioned as a first
choice. The strong spirituality that seemed to
influence many aspects of their lives did not always
translate into church affiliation or attendance.
Others were interested in getting away from their
communities, going even to places where people
smoked to aid in building resistance. What seemed
most important was the composition of the group.
They wanted to be among other women to learn,
share feelings, and offer and receive social and
emotional support.

63. Conclusions
Our findings are based on a qualitative ap-
proach, and hence, the limitations in interpreting
this type of study data apply. Despite the method-
ological constraints, there are a number of relevant
implications for public health programs for these
populations. We observed that for women in our
groups, smoking was associated with relief from
the heavy burden of stress in their lives. It helped
them to cope with a hostile environment and the
extraordinarily difficult life situations that accentu-
ated their lack of social support. Furthermore, it
was an attainable and acceptable pleasure that had
enormous value for them. These women did not see
cancer as a health threat associated with smoking.
Moreover, they did not see other health problems
as urgent enough to motivate a change in their
smoking behavior. On the other hand, smoking
appeared to be intimately tied to their life experi-
ences, and when they felt productive and sup-
ported, they appeared more likely to consider
smoking cessation.
Within these groups, the women demonstrated a
natural reservoir of support for one another. They
shared common backgrounds as black women en-
gaged in continuing life struggles. There was a
readiness to share their common life experiences,
and the sharing revealed mutual empathy and
nonjudgmental support. The group context ad-
dressed many of the barriers described previously.
The social isolation was lessened by the presence of
sympathetic peers with limited claims on the others

64. in the group.
If smoking cessation interventions could be intro-
duced into such a context, the potential for sup-
port, so important in the quitting process, would
be great, since there would be an environment
where cessation was accepted and the experiences
of relapse, slips, and so on could be shared and not
judged. The challenge is to develop health promo-
tion programs that use the participants' strengths
and put the programs in the context of methods
that the participants perceive as useful and accept-
able.
The fact that the women enthusiastically em-
braced the idea of support groups and immediately
wanted to assume program ownership by shaping
its format gave evidence of their interest. Their
responses also suggest that the need for self-
reliance can be met if the women are active
participants in program development and imple-
mentation as partners with the health professionals.
Our experience and that of others (7), however,
suggests that attendance and participation are prob-
lematic when the program competes with the every-
day concerns of living.
How then might the effort differ? Although this
paper cannot offer specific answers, it does offer
insights important to the development of innovative
strategies by health administrators and providers.
First, these women clearly indicated that smoking
cessation cannot be the single focus or even the
primary focus. To increase the likelihood of suc-
cess, smoking cessation should be part of a pro-
gram that has other meaningful purposes for these

65. women. Cessation is most likely to occur in the
context of programs that have some perceived
relationship to improving the lives of these women.
Relevance to them will focus on issues that differ
from those usually associated with health promo-
tion. These women did not see a clear relationship
between smoking and major illness, even when they
had an illness. Future research with black smokers
May-June 1993, Vol. 108, No. 3 393
should consider these barriers, and their relevance
for other groups should be determined.
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394 Public HaIth Reports
FEDDBACK OF THE DISSCSSION
Please keep your commentaries focused on analysis of the
content, adding original thoughts/experiences and posting an
interesting question for group members to respond to.
250-30O WORDS OF DISCUSSION FOLLOWED BY TWO
RESPONSES 250-300 WORDS FOR THS DISSUSION AS
USUAL, THANKS.