This is the first study to report on tobacco-use behaviors among Chinese American smokers with medical conditions. Our study suggests that the smoker’s general state of health, more than the level of acculturation, influences levels of cigarette use and nicotine addiction. On average, IP had smoked fewer daily cigarettes in the past week than OP (4.4 vs. 11.9). IP were also less likely than OP to smoke when ill (12 vs. 24%), and IP had lower nicotine-dependence scores than OP (5.5 vs. 6.7).
In contrast to earlier population-based studies of Chinese smokers [8
], we did not find a significant association between acculturation, age, and tobacco-use behaviors after adjustment for health status. Instead, our study suggests that individual tobacco-use behavior may largely be due to illness burdens among Chinese smokers with medical conditions. One intriguing finding is that being employed was significantly associated with higher average daily cigarette use, regardless of health status. The majority of employed participants (60%) worked in non-skilled jobs, such as restaurant or construction work. It is possible that stress associated with unskilled labor, coupled with workplaces that are likely to tolerate cigarette use, contributed to the higher average daily cigarette use found among this segment of smokers.
The rate of past-year quit attempts among our sample of smokers with medical conditions was considerably lower than rates reported by Chinese immigrants in the California Chinese American Tobacco Survey (CCATUS; 40 vs. 60%) [7
]. The lower rate of past-year quit attempts among our study participants compared to that of CCATUS smokers is surprising, given that smokers with illness burdens are more likely to attempt to quit than “healthier” smokers [4
]. One possible reason for this unexpected finding is that a substantial percentage of smokers in our sample were light smokers (e.g., ~40% smoked <5 cigarettes per day, and 68% smoked <10 cigarettes per day), compared to current smokers in the CCATUS study, only 25.8% of whom reported smoking 5 or fewer cigarettes per day [7
]. In our sample, smokers with medical conditions may have already reduced their cigarette use in prior quit attempts. It is plausible that these light smokers did not believe that further reduction or complete cessation of smoking would produce health benefits. For example, almost 50% of the current smokers in CCATUS endorsed the statement that smoking 5 cigarettes per day has the same health risk as not smoking at all (H Tang, University of California, San Diego, personal communication, May 21, 2008). Therefore, focused education may be necessary to increase the cessation rate, especially among light smokers in the Chinese community.
In light of the fact that the quit-attempt rate has been reported to be the single most significant factor in annual cessation rates across Chinese populations [6
], the lower rate of quit attempts in our study of smokers with medical conditions underscores an urgent need for effective cessation programs in health-care settings. Asian Americans are more likely than whites to be non-daily smokers [19
]. In addition, according to a study that controlled for self-reported health status, light smokers and non-daily smokers are more likely to want to quit than daily smokers [14
]. In our study, close to 1 in 4 smokers (24%) reported not smoking on the interview date or on the day prior to hospital admission. The relatively high numbers of non-daily smokers and light smokers among these smokers with medical conditions suggests that clinicians can play a critical role in identification and assessment of smokers in health-care settings, as well as in offering treatment to smokers in those settings. In particular, IP smokers—who were more likely than OP to be light smokers and less nicotine dependent—should be aggressively targeted for intervention. Given the severity of their disease profiles, hospitalization provides an opportune moment to advise IP smokers to quit. However, some clinicians may perceive smokers with worse illness burdens as having greater nicotine dependence, as not being receptive to cessation advice, and as having a lower probability for cessation success; thus some clinicians may be less inclined to provide appropriate intervention. In addition, recent data suggests that non-daily smokers were asked or advised about smoking cessation less often than daily smokers [15
]. Thus, clinicians may incorrectly assume that smokers who consume five or fewer cigarettes per day are not addicted to nicotine, especially when these light smokers do not exhibit withdrawal symptoms during periods of abstention, such as hospitalization. Our study suggests that it is critical to inform clinicians that they are important facilitators of smoking cessation, and that they have a prime opportunity to improve the health of their patients who smoke.
Our sample of smokers was recruited primarily from health-care settings and composed of older immigrant men who spoke no English and had low educational levels. Many were retired and only about 40% were employed, either part- or full-time. As a result, more than half of participants reported annual household income of less than $20,000. This particular combination of socio-demographic characteristics (older age, poor, less education, and low English proficiency) suggests that our participants would likely encounter tremendous barriers in seeking appropriate and affordable smoking cessation treatment services. Our study confirms large gaps in tobacco treatment services in the San Francisco Bay Area for Chinese-speaking smokers. During the study period, smoking cessation treatment programs for Chinese speakers were not available at any of the participating hospital sites. Although one HMO offered a smoking cessation group counseling program for outpatients, the program was not accessible to Chinese-speakers. Moreover, the seriousness of medical conditions, particularly among IP smokers (with >75% tobacco-related illnesses), and the long duration of their tobacco use (an average of 39 years), underscores the urgent need for timely cessation interventions, particularly in health-care facilities located in or near Chinese neighborhoods.
Several limitations of this study should be noted. Because of the study’s selection criteria, the sample population could differ from other Chinese American smokers with respect to socio-demographic characteristics and health status. For example, the participants in this study were not randomly selected. Rather, smokers with medical conditions were recruited from hospitals and clinics located in or near Chinese neighborhoods. This selection criterion may bias our results, producing not only a sicker and older population, but also a population with ready access to health care. Participants’ characteristics such as education, income, acculturation, and health needs may be different from smokers in other settings. The participants’ willingness to quit smoking was another criterion used to enroll smokers into the study. Thus, our sample population could differ from the general population, in which some smokers have little or no interest in quitting. In addition, the study relied on self-reported smoking behavior, and the self-reported medical diagnoses of about 20% of the smokers recruited through media outreach were not verified. Both factors may limit the study’s validity. However, we consider these to be minor limitations, given that prior studies comparing self-reported medical history with verified medical records found substantial agreement (>90% sensitivity and specificity), particularly for conditions related to cardiovascular diseases and diabetes [21
]. Lastly, our sample of smokers included a small number of women (~9%). It should be noted that a low smoking prevalence (<5%) has been reported among Chinese women in the US [7
]. Thus, the findings from CCSCP may not be generalizable to the entire population of Chinese American smokers.
Notwithstanding these limitations, the findings from this study point to both a critical need and tremendous opportunities to implement effective language- and culture-specific smoking-cessation interventions in health-care settings. Future tobacco treatment studies should pay particular attention to health status and illness burden among smokers in order to provide a more accurate assessment of needs, such as elucidating barriers to smoking-cessation treatment in health-care settings.