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Tobacco use, secondhand smoke exposure and their related knowledge, attitudes and behaviors among Asian Americans
Addictive Behaviors 30 (2005) 725 – 740
Tobacco use, secondhand smoke exposure and their related knowledge, attitudes and behaviors among Asian Americans Grace X. Maa,b,*, Steven E. Shiveb,c, Yin Tanb, Jamil I. Toubbeha,b, Carolyn Y. Fanga,b,d, Rosita L. Edwardsb a
Department of Public Health, College of Health Professions, Temple University, 304A Vivacqua Hall, P.O. Box 2843, Philadelphia, PA 19122-0843, USA b Center for Asian Health, College for Health Professions, Temple University, 1415 N. Broad Street, Suite 116, Philadelphia, PA 19122-0843, USA c Department of Health, East Stroudsburg University, DeNike Hall, 200 Prospect St., East Stroudsburg University, East Stroudsburg, PA 18301-2999, USA d Division of Population Science of Fox Chase Cancer, 510 Township Line Road, Third Floor, Cheltenham, PA 19012, USA
Abstract The present study examined tobacco use, secondhand smoke exposure and related knowledge, attitudes and behaviors among Asian Americans in the Delaware Valley of Pennsylvania and New Jersey, and the relationship between acculturation and smoking, social influence patterns on smoking, and stages of change of smoking among Asian subgroups. Study sample was 1174 Chinese, Koreans, Vietnamese, Cambodians, and other Asians. Findings revealed mean age of initiation to be 18.3, 40% ever and 30% current users. Significant differences were reflected in smoking by gender, ethnicity, educational level, marital and employment status. While knowledge and attitudes about smoking and secondhand smoke were associated with these variables, ethnic pride and smoking status played significant roles. Fathers and brothers had greater social influence on young male smoking behavior; smoking friends had influence on both genders. Stages of change of smoking and acculturation impact
* Corresponding author. Department of Public Health, College of Health Professions, Temple University, 304A Vivacqua Hall, P.O. Box 2843, Philadelphia, PA 19122-0843, USA. Tel.: +1 215 204 5108, +1 215 787 5434; fax: +1 215 787 5436. E-mail address: [email protected] (G.X. Ma). 0306-4603/$ - see front matter D 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2004.08.018
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on smoking varied with gender, age, and time living in the U.S. Findings provide comprehensive insights into tobacco use and related KAB among Asian Americans that reflect the need for developing culturally appropriate programs for this underserved population. D 2004 Elsevier Ltd. All rights reserved. Keywords: Tobacco use; Secondhand smoke; Knowledge; Attitude; Behavior; Asian Americans
1. Introduction Asian Americans are the fastest growing ethnic/racial group in the U.S., increasing 47% nationwide and 75% in the Delaware Valley region of PA and NJ over the past 10 years (Bureau of the Census, 2000). Smoking rates among Asian Americans vary according to ethnic subgroup, with estimates ranging from 35% to 72% (Centers for Disease Control and Prevention [CDC], 1997; Jenkins, McPhee, Ha, Nam, & Chen, 1995; Moeschberger et al., 1997; Wiecha, Lee, & Hodgkins, 1998; Yu, Chen, Kim, & Abdulrahim, 2002). These figures are higher than for the general U.S. population which range from 21.2% to 24.4%, with higher use among males (CDC, 2001). Despite its rapid growth and its overall high rates of smoking, few tobacco control efforts have targeted this population for prevention and intervention programs. Neglect has led most Asian subgroups to limited access to information about tobacco use and associated risks, as well as maintenance of high rates of tobacco use and its consequences—chronic health problems and early death (Schneider Institute for Health Policy, 2001). 2. Tobacco use: prevalence, knowledge, attitudes and behaviors Asian American populations have long been cited as having the lowest smoking prevalence rates (U.S. Department of Health and Human Services [USDHHS], 1998; American Lung Association [ALA], 2002). The ALA notes that among U.S. racial and ethnic populations, Asians and Pacific Islanders have the lowest current smoking rate (15%), a rate substantially lower than that for American Indians/Alaskan Natives (41%), African Americans (24%), Whites (24%), and Hispanics (18%) (ALA, 2002). Such aggregate data, however, mask discrepancies in smoking rates among Asian American subgroups and between genders in the same subgroups. The exclusion of non-English proficient Asian Americans from smoking surveys has further masked the high prevalence rates of smoking in these populations. Over 60% of the Asian American population is comprised of new immigrants who lack English proficiency. Current smoking rates vary among Asian American subgroups and geographic regions surveyed. Rates for Vietnamese males ranges between 35% and 56% (Moeschberger et al., 1997; Wiecha et al., 1998); for combined gender, the rate is 29% (Jenkins et al., 1995). Rates for Cambodian males are 35–55% (Moeschberger et al., 1997; USDHHS, 1990); for Laotian, 47–72% (Levin, Nachampassach, & Xiong, 1988); Korean 39% (Kim et al., 2000;
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Moeschberger et al., 1997); and for Chinese 28–34% (CDC, 1992; Yu et al., 2002). No reliable data are available for either females or for combined gender for the latter four ethnic subgroups. Smoking is primarily a male behavior and varies significantly among male subgroups. This is particularly evident in Southeast Asian men who have one of the highest reported smoking rates in the U.S. (Jenkins et al., 1995; Moeschberger et al., 1997; USDHHS, 1998; Wiecha et al., 1998). Socio-demographic characteristics among Asian Americans have a significant influence on smoking prevalence patterns. Smoking rates decrease as a function of increased educational attainment (Jenkins et al., 1995; Thridandam, Fong, Jang, Louie, & Forst, 1998; Wiecha et al., 1998; Yu et al., 2002). Further, a large subset of Asian Americans is not aware of the relationship between certain types of cancer common among Asian smokers, and smoking behavior (Chen & Hawks, 1995; Chu, 1998; Doong, 1998; Ma, Shieve et al., 2002) and the preventable nature of cancer (Averbach et al., 2002; Chen et al., 1993; Yu et al., 2002). Factors associated with low levels of health knowledge (Brownson et al., 1992) and gender-related differences in health knowledge among Asian Americans have not been thoroughly examined. Current smoking status is associated with lower levels of knowledge about tobacco-related risks and having positive attitudes toward smoking (Shankar, GutierresMohamed, & Alberg, 2000; Wiecha et al., 1998). Knowledge and beliefs about the health consequences of smoking and attitudes towards smoking varies among Asian American subgroups. In general, Koreans are able to acknowledge relationships between smoking and lung disease, believe smoking to be detrimental to health, tend to be less fatalistic about cancer regardless of smoking status (Kim et al., 2000), and were more negative toward tobacco use than Chinese (Averbach et al., 2002; Yu et al., 2002). In most subgroups, however, knowledge levels varied as a function of the disease in question. Generally, Asian American subgroups acknowledge that smoking causes lung disease, but are less likely to establish a relationship between smoking and mouth or throat cancer, and heart disease (Averbach et al., 2002; Chen et al., 1993; Kim et al., 2000; Yu et al., 2002). The latter finding is consistent across all subgroups.
3. Secondhand smoke exposure Tobacco use affects nonsmokers as well as smokers (USDHHS, 2000). Secondhand smoke (SHS) leads to an estimated 3,000 lung cancer deaths and 62,000 coronary heart disease deaths annually (National Cancer Institute [NCI], 1999). It is especially harmful to children, causing respiratory and other health problems. One Healthy People 2010 objective (27-10) is to reduce the proportion of nonsmokers exposed to SHS to 45% (USDHHS, 2000). Research on smoking to date has focused on public beliefs about the personal health hazards of tobacco use, with fewer studies examining knowledge of and attitudes towards SHS. Studies show that respondents (81%) agree that exposure to SHS is dangerous to nonsmokers’ health (Glantz & Jamieson, 2000; USDHHS, 1986). While these attitudes
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toward SHS appear to be stable over time (Torabi, 1996), there are certain subsets of the population (e.g., elderly residents of long-term care facilities) who may be less aware of the adverse health effects of SHS (Carosella, Ossip-Klein, Watt, & Podgorski, 2002). Many Asian Americans are included in this sub-population. There is a correlation between knowledge and beliefs about the health effects of SHS and age, race/ethnicity, and smoking status. A study by Brownson and colleagues found that young individuals, African Americans, and never smokers were more likely to acknowledge the health risks of SHS for children’s health and were more annoyed by the smoke than older persons, Whites and current smokers. The majority of study respondents recognized that SHS was detrimental to children (Brownson et al., 1992). Several studies examined tolerance to SHS. Elder et al. (1992) reported that 59% of nonsmokers and 44% of smokers have asked someone not to smoke in certain situations within the past 12 months. In addition, 28% of nonsmokers and 29% of smokers believed that they would consider asking someone to refrain from smoking, while only 13% of nonsmokers and 26% of smokers reported they would do so. Younger, more educated, and those holding anti-tobacco attitudes were more likely to assert themselves (Davis, Boyd, & Schoenborn, 1990). The health risks of SHS are well known among a large segment of the U.S. population but are marginally known to Asian Americans. A major factor contributing to the lack of awareness is the dearth of research on the subject in these communities. This is compounded by the fact that many members of these communities are new arrivals from countries where tobacco use is far more tolerated than in the U.S. For example, a study of Vietnamese smokers, found that these smokers were less likely to acknowledge the harmful effects of SHS on children (Wiecha et al., 1998). Generally, while there is a plethora of research on awareness of the adverse health consequences of SHS, particularly in homes and public places (Averbach et al., 2002; Chen, Ferketich, Moeschberger, & Wewers, 2001; Kim et al., 2000), there is a gap in research about the potential relationship between SHS and behaviors to avoid or reduce exposure to this ubiquitous health hazard (Chen et al., 2001).
4. Social and acculturation influences on smoking behavior Research on the relationship between social influences and smoking behavior, in particular the influence of adult smokers on peers or younger Asian Americans, is sparse. Chen and associates found that the rate of smoking among Southeast Asian friends was high, indicating the importance of social influences in molding male smoking behavior. Laotian male smokers had the highest percentage of friends who smoked, followed by Cambodians, and Vietnamese (Chen et al., 1993). Acculturation provides a conceptual bridge for understanding the relationship between immigration and smoking behavior adaptation. Acculturation has a variable influence on smoking behavior among different populations, age and gender groups. Smoking is more prevalent among less acculturated men and more acculturated women (Chen et al., 1993; Lee
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et al., 2000; Moeschberger et al., 1997), and among adolescents, and smoking rates increase with acculturation levels (Chen, Unger, Cruz, & Johnson, 1999; Chen, Unger, & Johnson, 1999), observations that have special significance in these largely new immigrant communities. Measurement of acculturation includes variables such as language use, native food preparation and consumption, age of emigration to and length of residency in the U.S., parental birthplace, ethnicity of friends, and involvement in cultural groups and activities. The most important variable has been language use. It has been typically used to determine general adaptation to a new social setting, and for determining specific behaviors as tobacco use (Chen, Unger, Cruz, et al., 1999). Results are somewhat inconsistent with regard to an association between higher levels of English proficiency and lower smoking rates among immigrant adults (Moeschberger et al., 1997; Wiecha et al., 1998) and should therefore be accepted with caution. Studies among Koreans (Kim et al., 2000), Chinese (Yu et al., 2002), and Vietnamese (Chen, 1993; Wiecha et al., 1998) have not shown reduced smoking rates with higher English proficiency. These studies also suggest that smoking might be confounded by educational level. Further, some studies have found that length of residency in the U.S. was inversely associated with smoking rates (Kim et al., 2000; Thridandam et al., 1998), while others have not (Wiecha et al., 1998; Yu et al., 2002). These discrepancies warrant further study.
5. Tobacco cessation Understanding the stages of smoking behavior change is critical in the development of successful smoking cessation programs. According to the Stages of Change Model (Prochaska, Redding, & Evers, 1997) behavioral modification involves progress through a series of five stages: precontemplation (no intention to quit), contemplation (intends to quit within the next 6 months), preparation (intends to quit within 1 month or less), action (in process of quitting within past 6 months), and maintenance (behaviors to prevent relapse). Variables such as age and race/ethnicity predict stages of change associated with smoking behavior (Jenkins et al., 1995; Moeschberger et al., 1997; Wiecha et al., 1998). Older Southeast Asian men (N44 years of age) were almost 10 times as likely to quit smoking as the youngest age group (b24 years) (Moeschberger et al., 1997). Vietnamese in Massachusetts and California were far less likely than the general population to think of quitting smoking, and Cambodians were more likely to quit smoking than Laotians and Vietnamese (Moeschberger et al., 1997). Further, Laotian men tended to be in the contemplation stage, and Cambodian and Vietnamese more likely to be in the precontemplation stage (Chen et al., 1993). For Chinese, approximately two-thirds of smokers in Boston’s Chinatown were found to be in the contemplation stage (Averbach et al., 2002). Other variables, such as gender and educational level, discussed later, also affect quitting. Although variations regarding stages of smoking behavior change were found among Asian America subgroups, in general, they were less likely to be thinking about
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quitting than the population at large, suggesting the difficulty of targeting this population for smoking cessation.
6. Purpose of the current study The Asian Tobacco Education, Cancer Awareness and Research (ATECAR) project of the Center for Asian Health, Temple University, Philadelphia, PA, was established to serve PA and NJ Asian American communities in response to two major needs in these populations, tobacco control and prevention and reduction in incidence of and risk behaviors for cancer. ATECAR’s overriding goal was to further understanding of the etiology of smoking behavior among its target population and to develop a foundation for a viable, culturally appropriate and comprehensive program for tobacco use prevention, intervention and cessation. A parallel goal was to establish, through research, education, community involvement, and policy development a viable infrastructure that would lead to sustainable, community-based efforts to counter tobacco use and tobacco industry advertising. As a first step in achieving its goals, ATECAR conducted a comprehensive baseline study that contributed conceptually to community-based participatory research (CBPR). This article represents an overview of the main findings and other salient issues associated with tobacco use among Asian Americans.
7. Methods 7.1. Sample selection A cross-sectional research method was used to conduct this comprehensive baseline epidemiological study. To obtain a representative sample, a stratified-cluster proportional sampling technique was adapted for the study (Federer, 1991). The sample size was determined by using a statistical power analysis and inflated by an anticipated response rate to ensure an adequate number of participants. A current list of Asian American community organizations (N=52) in the Delaware Valley region of PA and southern NJ was identified by an Asian Community Cancer Coalition, established by ATECAR, and other community partners. The region has large communities representing a range of ethnic subgroups. Twenty-six organizations were randomly sampled as clusters and then stratified based on language subgroups: Chinese, Korean, Vietnamese, and Cambodians. Participants (n=1374) were recruited from these organizations. Subgroup sample sizes were determined by a proportional allocation procedure based on population proportion data obtained from the Census Bureau. Cambodians, representing only 5% of Asians in the region, were oversampled to ensure an adequate sample size. Among the participants recruited, 1174 completed the survey. All participants were (1) of Asian descent, (2) affiliated with the selected community organizations, (3) 14 years of age or older and, (4) voluntary participants in the survey. Study protocols were approved by the Temple University Institutional Review Board.
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8. Sample characteristics Respondent characteristics reported included ethnic subgroup, gender, age, and educational level. The ethnic groups were Chinese, Korean, Vietnamese, Cambodian, and bOtherQ. Educational level was measured by the highest degree attained.
9. Measures and instrument A multi-lingual questionnaire was developed, back-translated, and pilot-tested for reliability, validity, and cultural appropriateness. A 77-item questionnaire composed of 10 sections was developed in five languages: English, Cambodian, Chinese, Korean and Vietnamese. Administration time for each participant ranged between 20 and 25 min. To establish reliability and validity of the instrument and to verify data collection methods, a pilot test was conducted. Appropriateness of the questionnaire format, content validity, level of difficulty and length of time to finish the survey questionnaire were also determined. The sample for the pilot-test consisted of 50 adults and 10 health professionals. The pilot test sample was excluded from the main study. The face and content validities of the questionnaire were established by an expert panel. The Guttman split-half reliability coefficient (0.67) indicated that, overall, participants responded consistently to items in the questionnaire. The main measures that represented the majority of the questionnaire exhibited acceptable and significant correlation coefficients ( pb0.05). Key areas such as identification of ethnic origin, country of birth, smoking status, number of friends who smoke, cessation attempts, environmental smoke exposure, and beliefs about the stimulatory and addictive qualities of tobacco had significant correlations ( pb0.05), indicating strong internal consistency. The questionnaire was revised and finalized based on pilot test results. 9.1. Tobacco use and secondhand smoke We categorized respondents as nonsmokers (never smoked), former smokers (had not smoked during the past year), and current smokers (smoked at least once within the past year) (Ma, Shive, Tan, & Toubbeh, 2002). We used several indicators to analyze respondents’ knowledge of the hazards of tobacco use, as well as their level of tolerance of SHS. Among the indicators were the perceived risk of developing cancer or heart disease, knowledge of miscellaneous risks caused by tobacco use, and unwillingness to tolerate SHS. Perceived risk of developing cancer was measured by the participants’ response to the question, bCompared with nonsmokers, the risk for smokers to get cancer would be lower, the same, or higher?Q Perceived risk of developing heart disease was measured by asking participants if smoking is associated with lung, mouth, throat, esophagus, bladder, pancreas, cervix, kidney cancers, and heart disease. Knowledge of miscellaneous risks of tobacco use was measured by an index of 12 question statements posited to participants under a general question bIn your opinion, what do you think might happen to you if you smoke?Q The index included statements such as bSmoke won’t hurt my health and safety; I would develop
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breathing problems; I might develop lung cancer, and so on.Q Unwillingness to tolerate SHS was measured by an index of two questions, which measured whether respondents allowed visitors to smoke in their home and whether they asked visitors to extinguish their cigarettes. The index score was determined by summing the item answer values assessed on a 4-point ordinal scale: strongly disagree, disagree, agree and strongly agree to each of the 12 statements. In addition to analyzing the effect of demographic characteristics on these variables, we also examined the influence of other independent variables when appropriate. These variables included time living in the U.S., the level of ethnic pride, and knowledge of the dangers of SHS. 9.2. Social and cultural influences on smoking We conducted two studies in which we compared current smokers to nonsmokers. In the first, we analyzed a number of social influence variables in order to determine their influence on the smoking status of the respondent. Survey items allowed for the determination of current smoking status among family members and friends. Analysis was conducted on the effect of social influences, ethnicity, gender, age, and perceptions of normative behavior on the smoking status of the respondent. In a separate study, we examined the effect of cultural influences on smoking behavior. The variables in the study included length of time lived in the U.S. (b5 years, N6 years), frequency of speaking native language (never, sometimes, always), and frequency of native food consumption (never, sometimes, always). An acculturation index was developed from these two variables. Data from participants who responded dalwaysT to both survey questions were recoded to a lower acculturation level, while data from participants who responded dneverT or dsometimesT to the same questions were recoded to higher acculturation level. Respondents, age 21 and under, were analyzed separately from those over 21. 9.3. Tobacco cessation Two items measured current smokers’ readiness to quit smoking based on the stages of change model. Smokers who intended to quit bnowQ or bwithin 30 daysQ were categorized as being in the preparation stage of change (Prochaska et al., 1997). Smokers in this stage of change have been identified as ones who are both ready to quit and usually have a specific plan for quitting as, for example, enrolling in a cessation program.
10. Data collection procedures Surveys were administered in one-on-one and group formats. ATECAR staff, in collaboration with local community organization leaders, administered the survey to participants at each of the 26 community organization sites. Standardized training was provided to all survey administrators and bilingual translators onsite to ensure accuracy and consistency in survey administration. The questionnaire was translated into Chinese,
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Korean, Cambodian, and Vietnamese. Back translation was performed to ensure accuracy. Participants had the option of completing the questionnaire in English or in the appropriate translated version. Assistance was provided to those who were either unable to finish the survey on their own, or who preferred to respond verbally to the survey. Survey forms were collected onsite.
11. Data analysis We analyzed the data using SPSS version 10.0. Statistical tests used included the v 2 test for independence, the independent samples t-test, one-way analysis of variance, OLS multiple regression analysis, and logistic regression analysis. This article presents results in summary form. Unless otherwise indicated, all figures presented in Tables 1–3 are statistically significant. For more detailed results, the reader is referred to previous publications (Ma & Fleisher, 2003; Ma, Fang, Tan, & Feeley, 2003; Ma, Shive, Tan, & Toubbeh, 2002; Ma, Tan, Feeley, & Thomas, 2002; Ma, Tan, Toubbeh, & Su, 2003).
12. Respondent characteristics Respondent characteristics are shown in Table 1. The sample (n=1174) consisted of Chinese (34.9%), Koreans (37.1%), Vietnamese (16.7%), Cambodians (8.5%) and bOtherQ Table 1 Respondent characteristics Respondent characteristics
Current smoking status
Ethnic group Chinese Korean Vietnamese Cambodian Other
%, N=1174 34.9 37.1 16.7 8.5 2.7
%, N=1174 24 27 40 30 22
Gender Male Female
55.2 44.8
42 14
Highest degree attained Elementary School High School Trade School or Associates Degree College Degree Graduate Degree
10.1 37.3 10.2 25.7 16.8
32 31 36 29 22
Age (mean, S.D.)
41.4 (16.5)
–
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(2.7%). Due to its small size, the bOtherQ group was excluded from some of our analyses. Men represented 55.2% of the sample. High school graduates (37.3%) represented the most frequent educational level. The mean age of respondents was 41.4 years (Ma, Shive et al., 2002).
13. Tobacco use and knowledge and attitudes The current smoking rate was 29% (Table 1) (Ma, Shive et al., 2002). There were significant differences in the current smoking rate by ethnic group, gender, and education. Smoking was most prevalent among Vietnamese (40%), followed by Cambodians (30%), Koreans (27%), Chinese (24%), and bOtherQ (22%). Men (42%) were more likely to be smokers than women (14%). Higher levels of education are generally associated with a lower smoking rate. Those with graduate degrees had the lowest rate (22%). The pattern was not linear, however, as respondents with trade school/associate degrees had the highest rate, 36%. The study also revealed a significant difference in age at initiation of smoking among the subgroups (F(4, 412)=9.7, p b0.001) (Ma, Shive et al., 2002). Cambodians (mean=14 years, S.D.=4.3) began using cigarettes at a significantly earlier age than did Chinese (mean=18.1 years, S.D.=5.3). Koreans (mean=19.8 years, S.D.=6.4) initiated use significantly later than Vietnamese (mean=16.9 years, S.D.=5.1) and Cambodians. Furthermore, among all smokers, friends (64.0%) were the most frequently reported initial source of tobacco, followed by stores (23.5%), family members (4.0%), and vending machines (0.4%) (Ma, Shive et al., 2002). Differences in initial source of tobacco across subgroups were not significant. Table 2 shows the results for knowledge of tobacco use and its association with the risk of getting cancer, heart disease and multiple health risks. The term bhigherQ means that the listed group had a significantly ( pb0.05) greater level of knowledge of the risk than the comparison group. In general, both Chinese and Korean respondents were at less risk, that is, had greater levels of knowledge than Southeast Asian (Vietnamese and Cambodian) respondents. Chinese respondents were more knowledgeable than Southeast Asians about the cancer risk. Korean respondents were more knowledgeable about risks of cancer, heart disease, and multiple health risks. Women were more knowledgeable than men about the risks of cancer and heart disease. Higher levels of education were associated with higher scores for all three variables. Former smokers outscored current smokers on three of the four questions, while nonsmokers outscored current smokers on all four. Age had a limited association with knowledge. Older respondents were more knowledgeable than younger respondents for cancer risk. Those with higher levels of ethnic pride exhibited greater knowledge of multiple health risks. Former and nonsmokers had the least favorable attitudes toward smoking compared to current smokers. Korean and Chinese respondents reported less favorable attitudes toward tobacco related health risks compared to Vietnamese and Cambodian respondents. Those who
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Table 2 Knowledge levels of the association of tobacco use with risk of cancer, heart disease, multiple health risks, and intolerance of secondhand smoke N=1174
Knowledge of cancer risk
Knowledge of heart disease risk
Knowledge of multiple health risks
Intolerance of secondhand smoke
Chinese (versus Southeast Asian) Korean (versus Southeast Asian) Female (versus male) Educational level Former smoker (versus current smoker) Nonsmoker (versus current smoker) Age Ethnic pride Time living in the U.S. Knowledge of secondhand smoke dangers
higher
n.s.
n.s.
higher
higher
higher
higher
n.s.
higher higher n.s.
higher higher higher
n.s. higher higher
n.s. higher higher
higher
higher
higher
higher
higher N/A N/A N/A
n.s. N/A N/A N/A
n.s. higher N/A N/A
n.s. N/A higher higher
higher=a significantly ( pb0.05) higher level of knowledge (columns 1–3) or significantly greater intolerance of secondhand smoke (column 4). n.s.=no significant difference among groups. N/A=the relationship between this independent variable and the dependent variable was not studied.
had higher education levels, women and those with high ethnic pride reported being less favorable toward smoking.
14. Exposure and intolerance to secondhand smoke Among participants, 38.2% reported at least one person smoking at home, 39.9% reported they were exposed to SHS in the workplace, and 57.6% reported that smoking was allowed in the restaurants they patronized. Chinese had the highest level of unwillingness to tolerate SHS compared to Southeast Asian (Vietnamese and Cambodian) respondents (Table 2). Higher levels of education were associated with higher intolerance of SHS. Nonsmokers and former smokers were more likely to be intolerant of SHS than current smokers. Those who lived in the U.S. longer showed a greater level of intolerance to SHS than those who lived in the U.S. a shorter period of time. Intolerance of SHS also increased with knowledge of its dangers.
15. Social and cultural influences on smoking The greatest social influence on smoking for both men and women was the number of friends who smoked. The more friends a respondent had who smoked, the more likely he
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or she was a current smoker. Men who had a father who currently smoked were more likely to smoke, but a smoking father was not a predictor of smoking for women. Additionally, current smokers were more likely than nonsmokers to believe that a majority of the people their age were smokers. For respondents age 21 and under, time living in the U.S. had a strong influence on smoking behavior. Those living in the U.S. 6 years or longer were more than six times as likely to smoke than those who lived 5 years or less. The effect of time living in the U.S. on the likelihood of smoking for our respondents 21 years and younger remains after controlling for age of the respondent. For all respondents, a low level of acculturation was weakly associated with a greater likelihood of smoking.
16. Tobacco cessation Table 3 shows the differences in being in the preparation stage of change by ethnic group, gender, and educational level 4. Vietnamese (45%) had the largest proportion of smokers in the preparation stage, followed by Koreans (41%), Cambodians (38%), and Chinese (33%). The groups that appeared to show the highest smoking rates were the ones most likely to be in the preparation stage, that is, the most likely to have an intention to quit within 1 month.
Table 3 Preparation stage rate by ethnic group, gender, and educational level % Ethnic group (n=251) Chinese Korean Vietnamese Cambodian Othera
33 41 45 38 –
Gender (n=256) Male Female
41 36
Educational Level (n=250) Elementary school High school Trade School/Associate Degree College Graduate school
46 47 30 38 28
a
There were only seven current smokers in the dOtherT group. This group was not examined in the Stages of Change study.
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Women (36%) were less likely to be in the preparation stage than men (41%), and those with elementary and high school education are more likely to be in this stage than those in the higher level of education groups. If respondents in the preparation stage do quit, however, there is no guarantee that they will not relapse. Of those who are current smokers, 50% had quit at least once in the past. Approximately 84% of respondents could not name a cessation program and 69% of the smokers had never been advised by a health care professional to quit. Among current smokers, 50.3% have tried at least one method to quit and 24.5% had tried using the bcold turkeyQ method.
17. Discussion Results of this study indicate that smoking is more prevalent among Asian Americans than in the general population. Although women in the study had a lower smoking rate than women reported in the Behavioral Risk Factor Surveillance Survey of 2000 (BRFSS) (CDC, 2000) (14% and 21.2%, respectively), the smoking rate of 42% for men is considerably higher than the men’s rate of 24.4% reported by the BRFSS. The combined rate for men and women in this study is 29%, indicating that smoking is an area of particular concern in these communities. Consistent with previous studies (Jenkins et al., 1995; Thridandam et al., 1998; Wiecha et al., 1998; Yu et al., 2002), it was found that high prevalence smoking rates were associated with lower levels of education. Additionally, smoking rates varied greatly among ethnic groups as, for example, the difference in rates between Vietnamese (40%) and Chinese (24%). The consistently high rates of smoking in this population, the differences in smoking rates among subsets of the population, and the association of smoking with lower levels of education reflect not only an urgent need to educate this community about the risks associated with tobacco use, but also the need for development of culturally specific programs to counter these smoking trends. The findings on SHS exposure among Vietnamese and Cambodians further underscore the need for these educational programs. Respondents (40% and 58%) from these communities reported exposure to SHS in the home (40%) and in restaurants (58%). Results of social and cultural influences on smoking corroborated prior research (Chen et al., 1993) and provided new insights into smoking behavior. Whereas Chen and associates found that number of friends who smoke was highly associated with smoking among male participants, we found this relationship to be true for both genders. We also found that having a father who smokes was associated with smoking among men, but not among women. With respect to level of acculturation, we found that for persons ages 21 and under, longer time living in the U.S. was strongly associated with higher smoking rates. We did not find a similar result for our older respondents. For all respondents, however, we found only a marginal association between low levels of acculturation and high levels of smoking. Although this is consistent with current literature on the subject, the high prevalence rates of smoking in our sample, as well as that in subsets of Asian American populations studied to date, would
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indicate the presence of a relationship, prompting us to conclude that there may be unexplored cultural variables that require further scrutiny. The finding that the groups least likely to start smoking—women, Chinese, and those with advanced levels of education—were the least likely to intend to quit once they started was surprising. This indicates that cessation strategies have to target discrete groups within Asian American populations, a finding that underscores the complexity of the problems of smoking and resistance to quitting in this population as well as the challenges health officials face in addressing them. Moreover, the fact that less than a third of our sample reported ever being informed by a health professional to quit smoking represents a modicum of attention by these professionals to the needs of their Asian American clientele. This survey highlighted the fact that while half of the smokers tried to quit, most (84%) smokers and nonsmokers could not name an available smoking cessation program—a salient opportunity to increase awareness of cessation programs in this community and to enhance their cultural relevancy to the population. We have one note of caution about our results. Because our study covered a discrete period of time, we are unable to make inferences about direction of causality particularly in our finding that current smokers were consistently less knowledgeable than former smokers and nonsmokers about the health risks of tobacco use. We are unclear as to whether a low level of knowledge caused some respondents to become current smokers, or whether current smokers tend to minimize the risks of tobacco relative to those who have never smoked or who have already quit. This is a topic that deserves further inquiry. In summary, our high rates of smoking indicate that smoking prevention and cessation programs are needed for all Asian Americans. The fact that the groups least likely to start smoking are often the least likely to intend to quit once they start indicates that virtually no subgroup of Asian Americans is free from risk. The problem is compounded, however, by the fact that certain groups within the larger Asian American ethnic groups are more in need of prevention programs than others, while still others are more in need of programs that help them quit effectively.
Acknowledgements This publication was supported by NIH-National Cancer Institute’s project ATECARCommunity Cancer Network, at Center for Asian Health, Department of Public Health, College of Health Professions, Temple University, Philadelphia, USA (Principal Investigator: Grace Ma, PhD).
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Tobacco use, secondhand smoke exposure and their related knowledge, attitudes and behaviors among Asian Americans Grace X. Maa,b,*, Steven E. Shiveb,c, Yin Tanb, Jamil I. Toubbeha,b, Carolyn Y. Fanga,b,d, Rosita L. Edwardsb a
Department of Public Health, College of Health Professions, Temple University, 304A Vivacqua Hall, P.O. Box 2843, Philadelphia, PA 19122-0843, USA b Center for Asian Health, College for Health Professions, Temple University, 1415 N. Broad Street, Suite 116, Philadelphia, PA 19122-0843, USA c Department of Health, East Stroudsburg University, DeNike Hall, 200 Prospect St., East Stroudsburg University, East Stroudsburg, PA 18301-2999, USA d Division of Population Science of Fox Chase Cancer, 510 Township Line Road, Third Floor, Cheltenham, PA 19012, USA
Abstract The present study examined tobacco use, secondhand smoke exposure and related knowledge, attitudes and behaviors among Asian Americans in the Delaware Valley of Pennsylvania and New Jersey, and the relationship between acculturation and smoking, social influence patterns on smoking, and stages of change of smoking among Asian subgroups. Study sample was 1174 Chinese, Koreans, Vietnamese, Cambodians, and other Asians. Findings revealed mean age of initiation to be 18.3, 40% ever and 30% current users. Significant differences were reflected in smoking by gender, ethnicity, educational level, marital and employment status. While knowledge and attitudes about smoking and secondhand smoke were associated with these variables, ethnic pride and smoking status played significant roles. Fathers and brothers had greater social influence on young male smoking behavior; smoking friends had influence on both genders. Stages of change of smoking and acculturation impact
* Corresponding author. Department of Public Health, College of Health Professions, Temple University, 304A Vivacqua Hall, P.O. Box 2843, Philadelphia, PA 19122-0843, USA. Tel.: +1 215 204 5108, +1 215 787 5434; fax: +1 215 787 5436. E-mail address: [email protected] (G.X. Ma). 0306-4603/$ - see front matter D 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2004.08.018
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on smoking varied with gender, age, and time living in the U.S. Findings provide comprehensive insights into tobacco use and related KAB among Asian Americans that reflect the need for developing culturally appropriate programs for this underserved population. D 2004 Elsevier Ltd. All rights reserved. Keywords: Tobacco use; Secondhand smoke; Knowledge; Attitude; Behavior; Asian Americans
1. Introduction Asian Americans are the fastest growing ethnic/racial group in the U.S., increasing 47% nationwide and 75% in the Delaware Valley region of PA and NJ over the past 10 years (Bureau of the Census, 2000). Smoking rates among Asian Americans vary according to ethnic subgroup, with estimates ranging from 35% to 72% (Centers for Disease Control and Prevention [CDC], 1997; Jenkins, McPhee, Ha, Nam, & Chen, 1995; Moeschberger et al., 1997; Wiecha, Lee, & Hodgkins, 1998; Yu, Chen, Kim, & Abdulrahim, 2002). These figures are higher than for the general U.S. population which range from 21.2% to 24.4%, with higher use among males (CDC, 2001). Despite its rapid growth and its overall high rates of smoking, few tobacco control efforts have targeted this population for prevention and intervention programs. Neglect has led most Asian subgroups to limited access to information about tobacco use and associated risks, as well as maintenance of high rates of tobacco use and its consequences—chronic health problems and early death (Schneider Institute for Health Policy, 2001). 2. Tobacco use: prevalence, knowledge, attitudes and behaviors Asian American populations have long been cited as having the lowest smoking prevalence rates (U.S. Department of Health and Human Services [USDHHS], 1998; American Lung Association [ALA], 2002). The ALA notes that among U.S. racial and ethnic populations, Asians and Pacific Islanders have the lowest current smoking rate (15%), a rate substantially lower than that for American Indians/Alaskan Natives (41%), African Americans (24%), Whites (24%), and Hispanics (18%) (ALA, 2002). Such aggregate data, however, mask discrepancies in smoking rates among Asian American subgroups and between genders in the same subgroups. The exclusion of non-English proficient Asian Americans from smoking surveys has further masked the high prevalence rates of smoking in these populations. Over 60% of the Asian American population is comprised of new immigrants who lack English proficiency. Current smoking rates vary among Asian American subgroups and geographic regions surveyed. Rates for Vietnamese males ranges between 35% and 56% (Moeschberger et al., 1997; Wiecha et al., 1998); for combined gender, the rate is 29% (Jenkins et al., 1995). Rates for Cambodian males are 35–55% (Moeschberger et al., 1997; USDHHS, 1990); for Laotian, 47–72% (Levin, Nachampassach, & Xiong, 1988); Korean 39% (Kim et al., 2000;
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Moeschberger et al., 1997); and for Chinese 28–34% (CDC, 1992; Yu et al., 2002). No reliable data are available for either females or for combined gender for the latter four ethnic subgroups. Smoking is primarily a male behavior and varies significantly among male subgroups. This is particularly evident in Southeast Asian men who have one of the highest reported smoking rates in the U.S. (Jenkins et al., 1995; Moeschberger et al., 1997; USDHHS, 1998; Wiecha et al., 1998). Socio-demographic characteristics among Asian Americans have a significant influence on smoking prevalence patterns. Smoking rates decrease as a function of increased educational attainment (Jenkins et al., 1995; Thridandam, Fong, Jang, Louie, & Forst, 1998; Wiecha et al., 1998; Yu et al., 2002). Further, a large subset of Asian Americans is not aware of the relationship between certain types of cancer common among Asian smokers, and smoking behavior (Chen & Hawks, 1995; Chu, 1998; Doong, 1998; Ma, Shieve et al., 2002) and the preventable nature of cancer (Averbach et al., 2002; Chen et al., 1993; Yu et al., 2002). Factors associated with low levels of health knowledge (Brownson et al., 1992) and gender-related differences in health knowledge among Asian Americans have not been thoroughly examined. Current smoking status is associated with lower levels of knowledge about tobacco-related risks and having positive attitudes toward smoking (Shankar, GutierresMohamed, & Alberg, 2000; Wiecha et al., 1998). Knowledge and beliefs about the health consequences of smoking and attitudes towards smoking varies among Asian American subgroups. In general, Koreans are able to acknowledge relationships between smoking and lung disease, believe smoking to be detrimental to health, tend to be less fatalistic about cancer regardless of smoking status (Kim et al., 2000), and were more negative toward tobacco use than Chinese (Averbach et al., 2002; Yu et al., 2002). In most subgroups, however, knowledge levels varied as a function of the disease in question. Generally, Asian American subgroups acknowledge that smoking causes lung disease, but are less likely to establish a relationship between smoking and mouth or throat cancer, and heart disease (Averbach et al., 2002; Chen et al., 1993; Kim et al., 2000; Yu et al., 2002). The latter finding is consistent across all subgroups.
3. Secondhand smoke exposure Tobacco use affects nonsmokers as well as smokers (USDHHS, 2000). Secondhand smoke (SHS) leads to an estimated 3,000 lung cancer deaths and 62,000 coronary heart disease deaths annually (National Cancer Institute [NCI], 1999). It is especially harmful to children, causing respiratory and other health problems. One Healthy People 2010 objective (27-10) is to reduce the proportion of nonsmokers exposed to SHS to 45% (USDHHS, 2000). Research on smoking to date has focused on public beliefs about the personal health hazards of tobacco use, with fewer studies examining knowledge of and attitudes towards SHS. Studies show that respondents (81%) agree that exposure to SHS is dangerous to nonsmokers’ health (Glantz & Jamieson, 2000; USDHHS, 1986). While these attitudes
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toward SHS appear to be stable over time (Torabi, 1996), there are certain subsets of the population (e.g., elderly residents of long-term care facilities) who may be less aware of the adverse health effects of SHS (Carosella, Ossip-Klein, Watt, & Podgorski, 2002). Many Asian Americans are included in this sub-population. There is a correlation between knowledge and beliefs about the health effects of SHS and age, race/ethnicity, and smoking status. A study by Brownson and colleagues found that young individuals, African Americans, and never smokers were more likely to acknowledge the health risks of SHS for children’s health and were more annoyed by the smoke than older persons, Whites and current smokers. The majority of study respondents recognized that SHS was detrimental to children (Brownson et al., 1992). Several studies examined tolerance to SHS. Elder et al. (1992) reported that 59% of nonsmokers and 44% of smokers have asked someone not to smoke in certain situations within the past 12 months. In addition, 28% of nonsmokers and 29% of smokers believed that they would consider asking someone to refrain from smoking, while only 13% of nonsmokers and 26% of smokers reported they would do so. Younger, more educated, and those holding anti-tobacco attitudes were more likely to assert themselves (Davis, Boyd, & Schoenborn, 1990). The health risks of SHS are well known among a large segment of the U.S. population but are marginally known to Asian Americans. A major factor contributing to the lack of awareness is the dearth of research on the subject in these communities. This is compounded by the fact that many members of these communities are new arrivals from countries where tobacco use is far more tolerated than in the U.S. For example, a study of Vietnamese smokers, found that these smokers were less likely to acknowledge the harmful effects of SHS on children (Wiecha et al., 1998). Generally, while there is a plethora of research on awareness of the adverse health consequences of SHS, particularly in homes and public places (Averbach et al., 2002; Chen, Ferketich, Moeschberger, & Wewers, 2001; Kim et al., 2000), there is a gap in research about the potential relationship between SHS and behaviors to avoid or reduce exposure to this ubiquitous health hazard (Chen et al., 2001).
4. Social and acculturation influences on smoking behavior Research on the relationship between social influences and smoking behavior, in particular the influence of adult smokers on peers or younger Asian Americans, is sparse. Chen and associates found that the rate of smoking among Southeast Asian friends was high, indicating the importance of social influences in molding male smoking behavior. Laotian male smokers had the highest percentage of friends who smoked, followed by Cambodians, and Vietnamese (Chen et al., 1993). Acculturation provides a conceptual bridge for understanding the relationship between immigration and smoking behavior adaptation. Acculturation has a variable influence on smoking behavior among different populations, age and gender groups. Smoking is more prevalent among less acculturated men and more acculturated women (Chen et al., 1993; Lee
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et al., 2000; Moeschberger et al., 1997), and among adolescents, and smoking rates increase with acculturation levels (Chen, Unger, Cruz, & Johnson, 1999; Chen, Unger, & Johnson, 1999), observations that have special significance in these largely new immigrant communities. Measurement of acculturation includes variables such as language use, native food preparation and consumption, age of emigration to and length of residency in the U.S., parental birthplace, ethnicity of friends, and involvement in cultural groups and activities. The most important variable has been language use. It has been typically used to determine general adaptation to a new social setting, and for determining specific behaviors as tobacco use (Chen, Unger, Cruz, et al., 1999). Results are somewhat inconsistent with regard to an association between higher levels of English proficiency and lower smoking rates among immigrant adults (Moeschberger et al., 1997; Wiecha et al., 1998) and should therefore be accepted with caution. Studies among Koreans (Kim et al., 2000), Chinese (Yu et al., 2002), and Vietnamese (Chen, 1993; Wiecha et al., 1998) have not shown reduced smoking rates with higher English proficiency. These studies also suggest that smoking might be confounded by educational level. Further, some studies have found that length of residency in the U.S. was inversely associated with smoking rates (Kim et al., 2000; Thridandam et al., 1998), while others have not (Wiecha et al., 1998; Yu et al., 2002). These discrepancies warrant further study.
5. Tobacco cessation Understanding the stages of smoking behavior change is critical in the development of successful smoking cessation programs. According to the Stages of Change Model (Prochaska, Redding, & Evers, 1997) behavioral modification involves progress through a series of five stages: precontemplation (no intention to quit), contemplation (intends to quit within the next 6 months), preparation (intends to quit within 1 month or less), action (in process of quitting within past 6 months), and maintenance (behaviors to prevent relapse). Variables such as age and race/ethnicity predict stages of change associated with smoking behavior (Jenkins et al., 1995; Moeschberger et al., 1997; Wiecha et al., 1998). Older Southeast Asian men (N44 years of age) were almost 10 times as likely to quit smoking as the youngest age group (b24 years) (Moeschberger et al., 1997). Vietnamese in Massachusetts and California were far less likely than the general population to think of quitting smoking, and Cambodians were more likely to quit smoking than Laotians and Vietnamese (Moeschberger et al., 1997). Further, Laotian men tended to be in the contemplation stage, and Cambodian and Vietnamese more likely to be in the precontemplation stage (Chen et al., 1993). For Chinese, approximately two-thirds of smokers in Boston’s Chinatown were found to be in the contemplation stage (Averbach et al., 2002). Other variables, such as gender and educational level, discussed later, also affect quitting. Although variations regarding stages of smoking behavior change were found among Asian America subgroups, in general, they were less likely to be thinking about
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quitting than the population at large, suggesting the difficulty of targeting this population for smoking cessation.
6. Purpose of the current study The Asian Tobacco Education, Cancer Awareness and Research (ATECAR) project of the Center for Asian Health, Temple University, Philadelphia, PA, was established to serve PA and NJ Asian American communities in response to two major needs in these populations, tobacco control and prevention and reduction in incidence of and risk behaviors for cancer. ATECAR’s overriding goal was to further understanding of the etiology of smoking behavior among its target population and to develop a foundation for a viable, culturally appropriate and comprehensive program for tobacco use prevention, intervention and cessation. A parallel goal was to establish, through research, education, community involvement, and policy development a viable infrastructure that would lead to sustainable, community-based efforts to counter tobacco use and tobacco industry advertising. As a first step in achieving its goals, ATECAR conducted a comprehensive baseline study that contributed conceptually to community-based participatory research (CBPR). This article represents an overview of the main findings and other salient issues associated with tobacco use among Asian Americans.
7. Methods 7.1. Sample selection A cross-sectional research method was used to conduct this comprehensive baseline epidemiological study. To obtain a representative sample, a stratified-cluster proportional sampling technique was adapted for the study (Federer, 1991). The sample size was determined by using a statistical power analysis and inflated by an anticipated response rate to ensure an adequate number of participants. A current list of Asian American community organizations (N=52) in the Delaware Valley region of PA and southern NJ was identified by an Asian Community Cancer Coalition, established by ATECAR, and other community partners. The region has large communities representing a range of ethnic subgroups. Twenty-six organizations were randomly sampled as clusters and then stratified based on language subgroups: Chinese, Korean, Vietnamese, and Cambodians. Participants (n=1374) were recruited from these organizations. Subgroup sample sizes were determined by a proportional allocation procedure based on population proportion data obtained from the Census Bureau. Cambodians, representing only 5% of Asians in the region, were oversampled to ensure an adequate sample size. Among the participants recruited, 1174 completed the survey. All participants were (1) of Asian descent, (2) affiliated with the selected community organizations, (3) 14 years of age or older and, (4) voluntary participants in the survey. Study protocols were approved by the Temple University Institutional Review Board.
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8. Sample characteristics Respondent characteristics reported included ethnic subgroup, gender, age, and educational level. The ethnic groups were Chinese, Korean, Vietnamese, Cambodian, and bOtherQ. Educational level was measured by the highest degree attained.
9. Measures and instrument A multi-lingual questionnaire was developed, back-translated, and pilot-tested for reliability, validity, and cultural appropriateness. A 77-item questionnaire composed of 10 sections was developed in five languages: English, Cambodian, Chinese, Korean and Vietnamese. Administration time for each participant ranged between 20 and 25 min. To establish reliability and validity of the instrument and to verify data collection methods, a pilot test was conducted. Appropriateness of the questionnaire format, content validity, level of difficulty and length of time to finish the survey questionnaire were also determined. The sample for the pilot-test consisted of 50 adults and 10 health professionals. The pilot test sample was excluded from the main study. The face and content validities of the questionnaire were established by an expert panel. The Guttman split-half reliability coefficient (0.67) indicated that, overall, participants responded consistently to items in the questionnaire. The main measures that represented the majority of the questionnaire exhibited acceptable and significant correlation coefficients ( pb0.05). Key areas such as identification of ethnic origin, country of birth, smoking status, number of friends who smoke, cessation attempts, environmental smoke exposure, and beliefs about the stimulatory and addictive qualities of tobacco had significant correlations ( pb0.05), indicating strong internal consistency. The questionnaire was revised and finalized based on pilot test results. 9.1. Tobacco use and secondhand smoke We categorized respondents as nonsmokers (never smoked), former smokers (had not smoked during the past year), and current smokers (smoked at least once within the past year) (Ma, Shive, Tan, & Toubbeh, 2002). We used several indicators to analyze respondents’ knowledge of the hazards of tobacco use, as well as their level of tolerance of SHS. Among the indicators were the perceived risk of developing cancer or heart disease, knowledge of miscellaneous risks caused by tobacco use, and unwillingness to tolerate SHS. Perceived risk of developing cancer was measured by the participants’ response to the question, bCompared with nonsmokers, the risk for smokers to get cancer would be lower, the same, or higher?Q Perceived risk of developing heart disease was measured by asking participants if smoking is associated with lung, mouth, throat, esophagus, bladder, pancreas, cervix, kidney cancers, and heart disease. Knowledge of miscellaneous risks of tobacco use was measured by an index of 12 question statements posited to participants under a general question bIn your opinion, what do you think might happen to you if you smoke?Q The index included statements such as bSmoke won’t hurt my health and safety; I would develop
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breathing problems; I might develop lung cancer, and so on.Q Unwillingness to tolerate SHS was measured by an index of two questions, which measured whether respondents allowed visitors to smoke in their home and whether they asked visitors to extinguish their cigarettes. The index score was determined by summing the item answer values assessed on a 4-point ordinal scale: strongly disagree, disagree, agree and strongly agree to each of the 12 statements. In addition to analyzing the effect of demographic characteristics on these variables, we also examined the influence of other independent variables when appropriate. These variables included time living in the U.S., the level of ethnic pride, and knowledge of the dangers of SHS. 9.2. Social and cultural influences on smoking We conducted two studies in which we compared current smokers to nonsmokers. In the first, we analyzed a number of social influence variables in order to determine their influence on the smoking status of the respondent. Survey items allowed for the determination of current smoking status among family members and friends. Analysis was conducted on the effect of social influences, ethnicity, gender, age, and perceptions of normative behavior on the smoking status of the respondent. In a separate study, we examined the effect of cultural influences on smoking behavior. The variables in the study included length of time lived in the U.S. (b5 years, N6 years), frequency of speaking native language (never, sometimes, always), and frequency of native food consumption (never, sometimes, always). An acculturation index was developed from these two variables. Data from participants who responded dalwaysT to both survey questions were recoded to a lower acculturation level, while data from participants who responded dneverT or dsometimesT to the same questions were recoded to higher acculturation level. Respondents, age 21 and under, were analyzed separately from those over 21. 9.3. Tobacco cessation Two items measured current smokers’ readiness to quit smoking based on the stages of change model. Smokers who intended to quit bnowQ or bwithin 30 daysQ were categorized as being in the preparation stage of change (Prochaska et al., 1997). Smokers in this stage of change have been identified as ones who are both ready to quit and usually have a specific plan for quitting as, for example, enrolling in a cessation program.
10. Data collection procedures Surveys were administered in one-on-one and group formats. ATECAR staff, in collaboration with local community organization leaders, administered the survey to participants at each of the 26 community organization sites. Standardized training was provided to all survey administrators and bilingual translators onsite to ensure accuracy and consistency in survey administration. The questionnaire was translated into Chinese,
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Korean, Cambodian, and Vietnamese. Back translation was performed to ensure accuracy. Participants had the option of completing the questionnaire in English or in the appropriate translated version. Assistance was provided to those who were either unable to finish the survey on their own, or who preferred to respond verbally to the survey. Survey forms were collected onsite.
11. Data analysis We analyzed the data using SPSS version 10.0. Statistical tests used included the v 2 test for independence, the independent samples t-test, one-way analysis of variance, OLS multiple regression analysis, and logistic regression analysis. This article presents results in summary form. Unless otherwise indicated, all figures presented in Tables 1–3 are statistically significant. For more detailed results, the reader is referred to previous publications (Ma & Fleisher, 2003; Ma, Fang, Tan, & Feeley, 2003; Ma, Shive, Tan, & Toubbeh, 2002; Ma, Tan, Feeley, & Thomas, 2002; Ma, Tan, Toubbeh, & Su, 2003).
12. Respondent characteristics Respondent characteristics are shown in Table 1. The sample (n=1174) consisted of Chinese (34.9%), Koreans (37.1%), Vietnamese (16.7%), Cambodians (8.5%) and bOtherQ Table 1 Respondent characteristics Respondent characteristics
Current smoking status
Ethnic group Chinese Korean Vietnamese Cambodian Other
%, N=1174 34.9 37.1 16.7 8.5 2.7
%, N=1174 24 27 40 30 22
Gender Male Female
55.2 44.8
42 14
Highest degree attained Elementary School High School Trade School or Associates Degree College Degree Graduate Degree
10.1 37.3 10.2 25.7 16.8
32 31 36 29 22
Age (mean, S.D.)
41.4 (16.5)
–
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(2.7%). Due to its small size, the bOtherQ group was excluded from some of our analyses. Men represented 55.2% of the sample. High school graduates (37.3%) represented the most frequent educational level. The mean age of respondents was 41.4 years (Ma, Shive et al., 2002).
13. Tobacco use and knowledge and attitudes The current smoking rate was 29% (Table 1) (Ma, Shive et al., 2002). There were significant differences in the current smoking rate by ethnic group, gender, and education. Smoking was most prevalent among Vietnamese (40%), followed by Cambodians (30%), Koreans (27%), Chinese (24%), and bOtherQ (22%). Men (42%) were more likely to be smokers than women (14%). Higher levels of education are generally associated with a lower smoking rate. Those with graduate degrees had the lowest rate (22%). The pattern was not linear, however, as respondents with trade school/associate degrees had the highest rate, 36%. The study also revealed a significant difference in age at initiation of smoking among the subgroups (F(4, 412)=9.7, p b0.001) (Ma, Shive et al., 2002). Cambodians (mean=14 years, S.D.=4.3) began using cigarettes at a significantly earlier age than did Chinese (mean=18.1 years, S.D.=5.3). Koreans (mean=19.8 years, S.D.=6.4) initiated use significantly later than Vietnamese (mean=16.9 years, S.D.=5.1) and Cambodians. Furthermore, among all smokers, friends (64.0%) were the most frequently reported initial source of tobacco, followed by stores (23.5%), family members (4.0%), and vending machines (0.4%) (Ma, Shive et al., 2002). Differences in initial source of tobacco across subgroups were not significant. Table 2 shows the results for knowledge of tobacco use and its association with the risk of getting cancer, heart disease and multiple health risks. The term bhigherQ means that the listed group had a significantly ( pb0.05) greater level of knowledge of the risk than the comparison group. In general, both Chinese and Korean respondents were at less risk, that is, had greater levels of knowledge than Southeast Asian (Vietnamese and Cambodian) respondents. Chinese respondents were more knowledgeable than Southeast Asians about the cancer risk. Korean respondents were more knowledgeable about risks of cancer, heart disease, and multiple health risks. Women were more knowledgeable than men about the risks of cancer and heart disease. Higher levels of education were associated with higher scores for all three variables. Former smokers outscored current smokers on three of the four questions, while nonsmokers outscored current smokers on all four. Age had a limited association with knowledge. Older respondents were more knowledgeable than younger respondents for cancer risk. Those with higher levels of ethnic pride exhibited greater knowledge of multiple health risks. Former and nonsmokers had the least favorable attitudes toward smoking compared to current smokers. Korean and Chinese respondents reported less favorable attitudes toward tobacco related health risks compared to Vietnamese and Cambodian respondents. Those who
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Table 2 Knowledge levels of the association of tobacco use with risk of cancer, heart disease, multiple health risks, and intolerance of secondhand smoke N=1174
Knowledge of cancer risk
Knowledge of heart disease risk
Knowledge of multiple health risks
Intolerance of secondhand smoke
Chinese (versus Southeast Asian) Korean (versus Southeast Asian) Female (versus male) Educational level Former smoker (versus current smoker) Nonsmoker (versus current smoker) Age Ethnic pride Time living in the U.S. Knowledge of secondhand smoke dangers
higher
n.s.
n.s.
higher
higher
higher
higher
n.s.
higher higher n.s.
higher higher higher
n.s. higher higher
n.s. higher higher
higher
higher
higher
higher
higher N/A N/A N/A
n.s. N/A N/A N/A
n.s. higher N/A N/A
n.s. N/A higher higher
higher=a significantly ( pb0.05) higher level of knowledge (columns 1–3) or significantly greater intolerance of secondhand smoke (column 4). n.s.=no significant difference among groups. N/A=the relationship between this independent variable and the dependent variable was not studied.
had higher education levels, women and those with high ethnic pride reported being less favorable toward smoking.
14. Exposure and intolerance to secondhand smoke Among participants, 38.2% reported at least one person smoking at home, 39.9% reported they were exposed to SHS in the workplace, and 57.6% reported that smoking was allowed in the restaurants they patronized. Chinese had the highest level of unwillingness to tolerate SHS compared to Southeast Asian (Vietnamese and Cambodian) respondents (Table 2). Higher levels of education were associated with higher intolerance of SHS. Nonsmokers and former smokers were more likely to be intolerant of SHS than current smokers. Those who lived in the U.S. longer showed a greater level of intolerance to SHS than those who lived in the U.S. a shorter period of time. Intolerance of SHS also increased with knowledge of its dangers.
15. Social and cultural influences on smoking The greatest social influence on smoking for both men and women was the number of friends who smoked. The more friends a respondent had who smoked, the more likely he
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or she was a current smoker. Men who had a father who currently smoked were more likely to smoke, but a smoking father was not a predictor of smoking for women. Additionally, current smokers were more likely than nonsmokers to believe that a majority of the people their age were smokers. For respondents age 21 and under, time living in the U.S. had a strong influence on smoking behavior. Those living in the U.S. 6 years or longer were more than six times as likely to smoke than those who lived 5 years or less. The effect of time living in the U.S. on the likelihood of smoking for our respondents 21 years and younger remains after controlling for age of the respondent. For all respondents, a low level of acculturation was weakly associated with a greater likelihood of smoking.
16. Tobacco cessation Table 3 shows the differences in being in the preparation stage of change by ethnic group, gender, and educational level 4. Vietnamese (45%) had the largest proportion of smokers in the preparation stage, followed by Koreans (41%), Cambodians (38%), and Chinese (33%). The groups that appeared to show the highest smoking rates were the ones most likely to be in the preparation stage, that is, the most likely to have an intention to quit within 1 month.
Table 3 Preparation stage rate by ethnic group, gender, and educational level % Ethnic group (n=251) Chinese Korean Vietnamese Cambodian Othera
33 41 45 38 –
Gender (n=256) Male Female
41 36
Educational Level (n=250) Elementary school High school Trade School/Associate Degree College Graduate school
46 47 30 38 28
a
There were only seven current smokers in the dOtherT group. This group was not examined in the Stages of Change study.
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Women (36%) were less likely to be in the preparation stage than men (41%), and those with elementary and high school education are more likely to be in this stage than those in the higher level of education groups. If respondents in the preparation stage do quit, however, there is no guarantee that they will not relapse. Of those who are current smokers, 50% had quit at least once in the past. Approximately 84% of respondents could not name a cessation program and 69% of the smokers had never been advised by a health care professional to quit. Among current smokers, 50.3% have tried at least one method to quit and 24.5% had tried using the bcold turkeyQ method.
17. Discussion Results of this study indicate that smoking is more prevalent among Asian Americans than in the general population. Although women in the study had a lower smoking rate than women reported in the Behavioral Risk Factor Surveillance Survey of 2000 (BRFSS) (CDC, 2000) (14% and 21.2%, respectively), the smoking rate of 42% for men is considerably higher than the men’s rate of 24.4% reported by the BRFSS. The combined rate for men and women in this study is 29%, indicating that smoking is an area of particular concern in these communities. Consistent with previous studies (Jenkins et al., 1995; Thridandam et al., 1998; Wiecha et al., 1998; Yu et al., 2002), it was found that high prevalence smoking rates were associated with lower levels of education. Additionally, smoking rates varied greatly among ethnic groups as, for example, the difference in rates between Vietnamese (40%) and Chinese (24%). The consistently high rates of smoking in this population, the differences in smoking rates among subsets of the population, and the association of smoking with lower levels of education reflect not only an urgent need to educate this community about the risks associated with tobacco use, but also the need for development of culturally specific programs to counter these smoking trends. The findings on SHS exposure among Vietnamese and Cambodians further underscore the need for these educational programs. Respondents (40% and 58%) from these communities reported exposure to SHS in the home (40%) and in restaurants (58%). Results of social and cultural influences on smoking corroborated prior research (Chen et al., 1993) and provided new insights into smoking behavior. Whereas Chen and associates found that number of friends who smoke was highly associated with smoking among male participants, we found this relationship to be true for both genders. We also found that having a father who smokes was associated with smoking among men, but not among women. With respect to level of acculturation, we found that for persons ages 21 and under, longer time living in the U.S. was strongly associated with higher smoking rates. We did not find a similar result for our older respondents. For all respondents, however, we found only a marginal association between low levels of acculturation and high levels of smoking. Although this is consistent with current literature on the subject, the high prevalence rates of smoking in our sample, as well as that in subsets of Asian American populations studied to date, would
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indicate the presence of a relationship, prompting us to conclude that there may be unexplored cultural variables that require further scrutiny. The finding that the groups least likely to start smoking—women, Chinese, and those with advanced levels of education—were the least likely to intend to quit once they started was surprising. This indicates that cessation strategies have to target discrete groups within Asian American populations, a finding that underscores the complexity of the problems of smoking and resistance to quitting in this population as well as the challenges health officials face in addressing them. Moreover, the fact that less than a third of our sample reported ever being informed by a health professional to quit smoking represents a modicum of attention by these professionals to the needs of their Asian American clientele. This survey highlighted the fact that while half of the smokers tried to quit, most (84%) smokers and nonsmokers could not name an available smoking cessation program—a salient opportunity to increase awareness of cessation programs in this community and to enhance their cultural relevancy to the population. We have one note of caution about our results. Because our study covered a discrete period of time, we are unable to make inferences about direction of causality particularly in our finding that current smokers were consistently less knowledgeable than former smokers and nonsmokers about the health risks of tobacco use. We are unclear as to whether a low level of knowledge caused some respondents to become current smokers, or whether current smokers tend to minimize the risks of tobacco relative to those who have never smoked or who have already quit. This is a topic that deserves further inquiry. In summary, our high rates of smoking indicate that smoking prevention and cessation programs are needed for all Asian Americans. The fact that the groups least likely to start smoking are often the least likely to intend to quit once they start indicates that virtually no subgroup of Asian Americans is free from risk. The problem is compounded, however, by the fact that certain groups within the larger Asian American ethnic groups are more in need of prevention programs than others, while still others are more in need of programs that help them quit effectively.
Acknowledgements This publication was supported by NIH-National Cancer Institute’s project ATECARCommunity Cancer Network, at Center for Asian Health, Department of Public Health, College of Health Professions, Temple University, Philadelphia, USA (Principal Investigator: Grace Ma, PhD).
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