INTRODUCTION Tobacco use is a major public health issue and the leading preventable cause of morbidity and mortality in the United States

Tobacco use is a major public health issue and the leading preventable cause of morbidity and mortality in the United States (U.S.). According to the current patterns of tobacco use, 24.6% of high school and 7.7% of middle school students in the U.S. have used tobacco products (CDC, 2015). To that point, in the City of Baltimore, an estimated 42% of youth have smoked throughout the course of their life, and approximately 12% are current tobacco users (CDC, 2007). Given the plethora of new and existing tobacco products such as electronic cigarettes, hookahs, flavored cigars, and smokeless tobacco, there is a critical need for innovative community-based preventive interventions, which allow local residents and schools to partner with a common goal.
Community-based participatory research (CBPR) and participatory action research (PAR) are promising orientations to research where community members and academicians collaboratively plan, implement, evaluate, and disseminate community relevant-research projects (Breckwich Vasquez et al., 2007). Specifically, Photovoice is a participatory action research (PAR) strategy used as a means to engage communities and create public health action (Wang, Burris, & Ping, 1996; Wang & Burris, 1997). During a Photovoice process, professionals supply community members with cameras and training to provide imagery and narratives about their community problems and assets (Minkler, 2008; Wang & Burris, 1994). In this way, Photovoice stimulates and supports crucial group discussion about relevant community health issues (e.g., tobacco, prostate cancer, breast cancer, HIV/AIDS, violence). Furthermore, Photovoice leads to the identification of practical solutions to community health issues through the application of photographs and narratives.

Photovoice has been used within community settings for additional purposes such as development of problem-solving skills (Streng et al., 2004), capacity building and youth empowerment in mobilizing peers and building teams (Strack et al., 2004), and leadership training (Madrigal et al., 2014). This study aims to explore the perspective of youth through their lenses by utilizing Photovoice as a school-based program (e.g., after school-school and summer) for both tobacco education and leadership training purposes.

Setting, Study Design, and Participants
The current community-based participatory research project was conducted in three urban middle schools in the Mid-Atlantic region and their respective neighborhoods in partnership with Communities Engaged and Advocating for a Smoke-free Environment (CEASE) initiative. CEASE is a community-university partnership committed to reduce tobacco-related health disparities and has served the underrepresented local communities for over ten years. CEASE has implemented Photovoice strategies to: 1) empower youth, 2) engage underserved communities, and 3) launch an anti-nicotine health promotion and disease prevention campaign.
A total of twenty-three youth participated in two photovoice projects (e.g., after-school and summer) to explore tobacco-related issues, which plague their communities. The students were recruited based on their interest in participating in community-based activities to learn more about how to increase the capacity of their neighborhoods’ through enhancing their capacity, with respect to various tobacco domains. Information about the project was shared with them and their parents by the respective community liaison, who worked directly with the school’s administrators, students, and families.

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Implementation, Data Collection, and Analysis
Participants were trained in photography, narrative development, and ethics. Students constructed their narrative statements utilizing the SHOWeD Method to focus on the development of key skills: observation, critical thinking, and leadership (Wallerstein & Berstein, 1998). For the after-school program, the photographs were taken within the community over a two-week period. For the summer program, the photographs were captured during a seven-week timeline. During the project’s conclusion, there were three photovoice exhibitions, which showcase the youth artwork and allowed each student to engage with exhibition attendees in a community forum.

All narrative statements and photographs associated with the photovoice project were coded. Two trained coders utilized a codebook to identify the respective themes and subthemes for narrative statements and themes only for photographs. Inter-rater reliability was achieved through coding deliberation if there were any codebook inconsistencies.

The middle school students (N=23) consisted of all African American students with slightly higher female participants (58%) than males (42%). They were between the ages of 10 and 15 years.
Findings revealed that the 196 narrative statements discussed six categories, six themes, and eight subthemes (table 1 and table 2). The themes included: Tobacco Use, Second Hand Smoking, Littering, Access, Advertisements (Ads) and Signs, and Impact. The subthemes were: Adult Male, Socializing, E-cigarette, Store, Perceived Social Norm, Harmful Effects, Awareness, and Empowerment. The 239 photographs associated with the photovoice project identified six themes (table 3): Tobacco Use (51), Second Hand Smoking (43), Littering (41), Access (39), Advertisements (Ads) and Signs (37), and Impact (28) (figure 1).
The thematic content of youth narratives and photographs highlighted: Tobacco Use as the act of habitual use of the tobacco plant leaf and its products, or nicotine delivery systems (such as E-cigarettes). Second Hand Smoking depicted the act of smoke inhaled involuntarily from tobacco being smoked by others. Littering lent itself behaviors regarding environmental debris including trash, cigarette butts, and other tobacco product wrappers. With respect to Access, it highlighted exposure to tobacco products or the ability to take such substances in one’s possession. Inasmuch, Advertisements (Ads) and Signs shed light on marketing of tobacco and tobacco-related products through signs, posters, billboards, magazines, or other announcements. Furthermore, Impact detailed positive and/or negative outcomes associated with tobacco.

The content analysis of the youth narratives provided an additional layer of subthemes on how youth discussed the tobacco-related issues of their community. More specifically, Adult Male identified a grown man or men smoking in some capacity or another; Socializing detailed the act of interacting in a group setting with two or more persons involved in tobacco-based activities; E-cigarette spoke to the identification of a device used to simulate the experience of smoking, having a cartridge with a heater that vaporizes liquid nicotine instead of burning tobacco; Store described a geographical place utilized to sell an array of goods/products including tobacco products; Perceived Social Norm discussed the nature of behaviors/practices that an individual believes is expected within his/her community; Harmful Effects dialogued the adverse outcomes relevant to wellness and well-being; Awareness told a story about the knowledge or perception of a situation dealing with tobacco; Empowerment articulated the ability of an individual to take control or make decisions about his/her personal life including health-related issues.

Photovoice has been identified as an important intervention to address significant community problems such as tobacco, which has specifically affected youth from underserved communities (Sheikhattari, Wagner, LaVeau, & Pettway, 2012; Strack, McGill, & McDonagh, 2004; Tanjasiri, Lew, Kuratani, Wong, & Fu, 2011). Through Photovoice, communities learn about different problems and get ideas on how to address them. The findings of this study provide important evidence of the various perspectives that youth can discuss while learning about various tobacco issues within the community. As such, Photovoice can serve as a tool for youth to be exposed to health education and life skills development.
More importantly, Photovoice can provide leadership training for youth along with a project that is tangible (Madrigal et al., 2014). This can allow for community leaders to mentor youth during the implementation of a Photovoice project; the Photovoice process can make room for leadership opportunities and application within the community. The teaching and learning of leadership development and enhancement can be difficult to accomplish within a classroom setting. Hence, Photovoice can take classroom education to the next level with respect to leadership training. Community leadership emphasizes a collaborative, iterative, and positive influential process based on the relationship and synergy between youth, adults, and elders for developmental community processes and sustainable capacity building (Kirk & Shutte, 2004).

In conclusion, through Photovoice, youth can potentially learn important leadership skills that could assist with securing a vested interest in their community, in order to make meaningful contributions that enhance health and wellness. Furthermore, they might be able to attain important critical thinking/problem solving skills, which is crucial in the shaping and formation of their future leadership abilities. Photovoice can be a promising tool for invoking positive leadership among youth for community development and enhancement. Youth are uniquely qualified as leaders because he/she can serve as liaison from school to community, in order to address key public health issues. This can further lead to the strengthening of underserved populations, which is critical in reducing health disparities and providing health solutions. Therefore, Photovoice might be able to change the traditional education models by employing novel learning techniques and producing favorable health outcomes.
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