Tobacco use has historically been a serious public health problem in the United States and worldwide. The 2007 National Health Interview Survey reported a smoking prevalence rate of 19.8% among adults (Centers for Disease Control and Prevention [CDC], 2007
). A 2007 report by CDC indicated a smoking prevalence rate of 23.9% for males and 18.0% for females (CDC, 2007
). Several independent studies have revealed higher smoking rates among Chinese Americans ranging between 22% and 34% (Hu et al., 2006
; Ma, Shive, Tan, & Toubbeh, 2002
; Ma, Tan, Toubbeh, & Su, 2003
; Shelley et al., 2004
; Yu, Chen, Kim, & Abdulrahim, 2002
). In New York City (NYC), one study of Chinese American smokers reported a prevalence rate of 29% and a lifetime smoking rate of 52% (Shelley et al.).
A large body of epidemiological research has established a relationship between tobacco use and a variety of diseases such as cancer, heart disease, stroke, and chronic obstructive pulmonary diseases (Kumra & Markoff, 2000
). Tobacco use today is the single most preventable cause of illness and death and is accountable for more than 438,000 deaths in the United States annually (CDC, 2005
). A CDC report of 2005 and an earlier report by the Department of Health and Human Services (U.S. DHHS)indicated that mortality caused by cigarette smoking is higher than that attributed to crack cocaine, AIDS, homicides, suicides, and alcohol use combined (CDC, 2005
; U.S. DHHS, 1998).
Asian Americans constitute one of the fastest growing ethnic groups in the United States, increasing from 7 to 13 million (about 72%) during the period of 1990–2000. The 2000 Census reported a population of 2.7 million Chinese Americans, an increase of 48% from 1990 (Barnes & Bennet, 2000
). NYC's Chinese population, the largest in the United States, is estimated to be 375,000 (Asian American Federation of New York Census Information Center [AAFNYCIC], 2004
), which does include many undocumented Chinese immigrants. Analysis of 2000 Census data by the AAFNYCIC indicates that a large subset of this population is foreign born (75%), has limited English proficiency (63%), does not have a high school diploma (42%), and is nearly a quarter (23%) indigent (AAFNYCIC). These factors pose additional barriers to smoking cessation. Lower levels of English proficiency, education level, and acculturation as well as recent immigrant status, for example, are associated with higher levels of current smoking among Chinese American men. These factors provide additional barriers for this population since limited English proficiency supports linguistic isolation and lack of access to health services that may promote smoking cessation. Furthermore, a cultural norm that promotes smoking among men can lead to social pressure that would increase resistance to cessation (Fu, Ma, Tu, Siu, & Metlay, 2003
; Hu et al., 2006
; Ma et al., 2004
; Yu et al., 2002
). A large subset of Chinese American males is less likely to report consideration of physician advice to quit smoking and hence is less likely to have adequate knowledge of early cancer symptoms (Fu et al.; Yu et al.). Typically, Chinese American smoking behaviors are culturally bound with adverse health issues related to smoking being dealt within the context of Chinese culture and traditional medicine (Hu et al., 2006
; Yu et al.).
There is a dearth of culturally appropriate smoking intervention programs to promote cessation within Chinese American communities. Accessibility to culturally unfamiliar intervention programs has not led to significant changes in smoking behaviors (Spigner, Yip, Huang, & Tu, 2007
). Research to date, however, has identified intervention strategies that could effect better quit and cessation outcomes. Two studies have shown that physician-led smoking interventions may lead to higher quit and cessation rates among Chinese Americans (Ferketich et al., 2004
; Spigner et al.).
Although knowledge about the adverse impact of tobacco use on the health of Chinese Americans in NYC is low, general awareness of the city's restrictive ordinances against smoking in public places has created a need in the community for culturally and linguistically specific smoking prevention and cessation programs. The city's Chinese community is composed largely of new immigrants, who, like their predecessors, adhere to Chinese cultural norms (Shelley et al., 2004
). Two studies by Spigner et al. (2007)
and Yu et al. (2002)
found that former Chinese smokers may not consider prevailing approaches to prevention and cessation, particularly nicotine replacement therapy (NRT), to be effective, which may have led to limited uptake in comparison with “cold turkey” methods. The authors note that the effectiveness of culturally appropriate therapies, especially those that relate to introduction of NRT, need further study.
Prochaska and DiClemente's (1983)
Transtheoretical Model (TTM) has often been applied to smoking cessation programs to stimulate behavior change. The core constructs of TTM, around which other dimensions are organized, are the stages of change: precontemplation, contemplation, preparation, action, and maintenance. These represent ordered categories to change problem behavior along a continuum of motivational readiness. Matching interventions to the specific stage of change is important to promoting retention in smoking cessation interventions (Prochaska, 1996
Few intervention studies, however, have targeted Chinese Americans, the largest subset of Asian ethnic groups in the United States. A generic Asian QUIT program was first developed and later tailored to specifically meet the cultural and linguistic needs of several Asian American ethnic communities, including Chinese (Ma, 1999
). Chinese QUIT is a smoking cessation intervention specifically tailored for Chinese American smokers. We not only developed all the smoking cessation protocols and participant materials in the Chinese language but also incorporated social and cultural factors that are critical for Chinese smokers, including Chinese values, Yin–Yang balance, male social status, coping with separation from extended families, availability of social support, role and relationship changes, limited language proficiency, and stigma in seeking smoking cessation services among others.
Our previous study (Ma et al., 2005
), which focused on Chinese and Korean American smokers, found that the 3-month quit rate for this ethnically mixed group was 59% and between 57% and 68% of participants had successfully moved from precontemplation to action and maintenance stages. In addition, Chinese and Korean American smokers showed increases in self-efficacy at 3 months and an initial (1-month) quit rate of 52.6%. This rate dropped significantly at 3-month postintervention, suggesting a need to incorporate the prevention of smoking relapse into cessation strategies (Fang et al., 2006
This study was guided by constructs from TTM (Prochaska & DiClemente, 1983
) and adapted motivational interviewing (AMI) strategies (Miller & Rollnick, 2002
). Transitions between stages of change are effected by a set of independent variables known as the processes of change. The TTM further incorporates a series of intervening or outcome variables that include decisional balance (the pros and cons of change), self-efficacy (confidence in the ability to change across problem situations), situational temptations to engage in problem behavior, and behaviors that are specific to the problem area. Also included among these intermediate or dependent variables would be any other psychological, environmental, cultural, socioeconomic, physiological, biochemical, or even genetic or behavioral variables that are specific to the problem being studied.
Motivational interviewing (MI) has been used extensively to help individuals overcome ambivalence, assist them in making behavioral changes through a collaborative relationship with counselors, recognize individual autonomy, and incorporate individual goals and values (Miller & Rollnick, 2002
). Based upon constructs of TTM, multiple sessions of MI can move individuals through the various stages of change using a combination of NRT (Mallin, 2002
) and education, recommendations, a list of options, the discussion of reactions, and follow-ups. Although the use of MI for smoking cessation has shown some promise, there is a need to test its effectiveness across different clinicians and populations (Dunn, Deroo, & Rivara, 2001
The specific aims of this study were (a) to pilot test the feasibility of Chinese QUIT, a combined culturally tailored smoking cessation program, which uses an AMI and a pharmacological NRT intervention among Chinese American smokers residing in NYC; (b) to examine the impact of Chinese QUIT on smoking reduction and quit rates specifically for the improved cognition of risk perceptions, self-efficacy, decisional balance (pros and cons of smoking), emotional distress, and nicotine dependence; and (c) to identify factors and techniques that can be used to modify or improve Chinese QUIT as well as assess potential long-term effects of this intervention among Chinese and other Asian American smokers.