This is the largest in-language study of tobacco-related behavior of Vietnamese Americans in California. In addition to its size and focus, strengths of this study include its culturally and linguistically competent survey methods and large surname sampling frame. The importance of using such methods and of disaggregating data by ethnic subgroup is reflected in the wide disparity () between the smoking prevalence among Vietnamese American men in our study (25%) versus general California men (16.5%; M. Modayil, Ph.D., personal communication, May 13, 2009, regarding unpublished results from the 2008 California Adult Tobacco Survey) and California Asian/Pacific Islander (English speaking only) men (14.9%; Al-Delaimy et al., 2008
). Similarly, the importance of disaggregating smoking prevalence by gender is reflected in our study’s low smoking prevalence among Vietnamese American female population (1%) compared with the general California female population (10.6%; M. Modayil, Ph.D., personal communication, May 13, 2009, regarding unpublished results from the 2008 California Adult Tobacco Survey) and California Asian/Pacific Islander (English speaking only) females (5.3%; Al-Delaimy et al.). This study highlights the importance of survey sampling methods appropriate to the population, such as using the Vietnamese surname list and using the appropriate language (English and Vietnamese) as determined by the individual respondent.
Figure 1. Comparison of smoking status for California Vietnamese male respondents, California Vietnamese Adult Tobacco Use Survey, 2008, and the California general male population (M. Modayil, Ph.D., personal communication, May 13, 2009, regarding unpublished results (more ...)
Our study’s estimates for Vietnamese male smoking prevalence are consistent with other recent estimates for California (California Health Interview Survey, 2009
; Nguyen et al., 2009
; Tang, Shimizu, & Chen, 2005
) and may be more accurate, given our study’s larger statewide sample size (four times the number of Vietnamese adults than the California Health Interview Survey). The fact that studies in other states report higher Vietnamese male smoking prevalence rates (Chae, Gavin, & Takeuchi, 2006
; Chan et al., 2007
; Wiecha et al., 1998
) may be due to several factors. California has one of the oldest tobacco control programs that includes in-language Asian media outreach and cessation services (Tang et al.). Additionally, the VCHPP began Vietnamese smoking cessation interventions during the 1990s (Jenkins, McPhee, et al., 1997
; Lai et al., 2000
; McPhee et al., 1995
One possible explanation for why the California Vietnamese male smoking prevalence rate has decreased but remains persistently higher than for men in the general California population is the continuing influx of new immigrants from Vietnam, where male smoking prevalence rates are much higher. About 12% of Vietnamese immigrants entered the United States in 2000 or later (Ponce et al., 2009
). Another explanation is that Vietnamese men are much lighter smokers than other Asian American men (Tong, Nguyen, Vittinghoff, & Perez-Stable, 2009
). Effective treatments for lighter smokers have not yet been defined—they may not be so addicted as to require medications to quit. Also, health care providers tend to assist heavier smokers (Fiore et al., 2008
Additionally, California Vietnamese female smoking prevalence has remained persistently low over the years (Jenkins et al., 1995
; Jenkins, McPhee, et al., 1997
; McPhee et al., 1992
; Tang et al., 2005
; Tong, Nguyen, et al., 2009
). This female phenomenon may be due to cultural factors since we did not find any difference in smoking status by age or acculturation measures, but the numbers of current female smokers were very small. Sustained targeting and development of effective health program strategies for the male immigrant population are crucial.
Three VCHPP community–based media-led smoking cessation interventions were conducted during the 1990s with mixed effectiveness. The first study (McPhee et al., 1995
) tested a 24-month multimedia smoking cessation intervention among Vietnamese men in Santa Clara County, CA; Vietnamese men in Houston, TX, served as controls. Following a media intervention, the proportion of recent quitters was greater in Santa Clara County than in Houston, but there was no significant intervention effect in either community. In the second study (Jenkins, McPhee, et al., 1997
), a similar but longer (36-month) media intervention among Vietnamese men in Alameda and San Francisco Counties (with Houston men again serving as controls) produced a statistically significant but modest reduction in smoking prevalence (36.1%–33.9%) and increase in recent quitters (7.2%–10.2%). In the third study (Lai et al., 2000
), two “Quit & Win” smoking cessation contests were advertised for Vietnamese smokers in Santa Clara County in 1995–1996; out of 89 smokers who participated, 72% reported being abstinent at 6 months.
The findings from the present study may help us to develop more targeted health programs for Vietnamese American smoking cessation. As a guiding framework for such programs, the Population Health Promotion Model integrates two important health concepts, population health and health promotion, to help determine “what, how, and with whom” one should take action to improve health: the full range of health determinants, comprehensive action strategies, and various levels of action (Hamilton & Bhatti, 1996
). For the “what” component of targeting health determinants, this study demonstrates that education and associated health behaviors are important. Vietnamese male current smokers have lower educational attainment and less knowledge than their never-smoker counterparts about the harms of smoking, particularly about addiction and light cigarettes. Vietnamese male current smokers also report more behaviors that may serve as triggers for smoking or relapse (Anda et al., 1990
; Leventhal, Ramsey, Brown, LaChance, & Kahler, 2008
; Shiffman, 2006
), with higher depression symptoms and report of alcohol intake. These findings are consistent with other studies of Vietnamese male current smokers (Chan et al., 2007
; Rahman et al., 2005
; Wiecha et al., 1998
For the “how” component of developing comprehensive action strategies, this study suggests that strengthening community outreach may have a greater effect than reorienting health services; this outreach should include Vietnamese doctors. Although Vietnamese male current smokers are more likely to be employed than their never-smoker counterparts, they less often have health insurance and make fewer doctor visits. Community outreach in places where smokers congregate is perhaps a better potential strategy. This study suggests that socializing with friends and smoking in coffee shops, restaurants, or bars are the two most frequently reported triggers for smoking. This common trigger of social situations and after meals was also reported in another study in Seattle (Chan et al., 2007
). The fact that media exposure was not significantly associated with smoking status in this study may be limited by the period of recall to the past month.
Regarding the “for whom” component of which level of society to target, besides acting directly on individuals, families and community groups may be also targeted. Vietnamese male current smokers were more likely than their never-smoker counterparts to be married or (among age-eligible men) to have had a Vietnamese military/police or reeducation camp experience. Social relationships, both close and distant ties, are thought to be important mediators of smoking behavior and facilitators of cessation (Christakis & Fowler, 2008
). Men who served in the Vietnamese military/police or had reeducation camp stays had a social norm of smoking during those periods; these groups may be targeted through community programs. For younger men, other social dynamics, including influence of this older generation of smokers, should be investigated. Although targeting the recent immigrant community makes sense given the greater male smoking social norm in Vietnam, the fact that the number of years of residence in the United States was not significantly associated with current or former smoking compared with never smoking, requires further exploration. The role of years of residence in the United States may be complicated in that recent immigrants may be more likely to quit than their counterparts in the countries of origin (Zhu, Wong, Tang, Shi, & Chen, 2007
), but longer term residents in the United States are also more likely to start smoking (U.S. Department of Health and Human Services, 1998
). The complex relationship among length of time, social factors, and smoking status for Vietnamese American men is also highlighted in our interaction analysis. One of the interactions with increasing age was with the Vietnamese military/reeducation camp experience variable. This interaction with increasing age was driven by the subset of men “born in the United States/not adults by 1975” who were more likely, relative to those who had no service, to be current or former smokers. However, simply being in this “born in the United States/not adults by 1975” category, relative to those who had no service, was not in itself predictive of being a current or former smoker in our primary multivariate analysis that controlled for age.
We examined the potential protective role of religious affiliation and found that there was a significant association between former smoking (vs. never smoking) and not being Buddhist (compared with other non-Christian religion or no religion); this association did not quite reach statistical significance (p
= .057) in its association with current smoking. Although a previous smaller survey found no association between religion and smoking status among Vietnamese men in Seattle (Chan et al., 2007
), the current findings suggest that a possible association between religion and tobacco use is worth exploring more. For example, religious affiliation has been suggested as a protective role for tobacco use among California’s South Asians (McCarthy et al., 2005
). Also, the majority of Buddhist smokers in Thailand and Muslim smokers in Malaysia believed that their religion discourages smoking, and over half reported their religious leaders encouraged them to quit (Yong, Hamann, Borland, Fong, & Omar, 2009
The findings in this study are subject to limitations. First, the information from this survey was based on self-report and smoking status was not validated by biochemical tests. However, self-reported population-based data on current smoking status have high validity in the general population when compared with measured serum cotinine levels (Caraballo, Giovino, Pechacek, & Mowery, 2001
). Second, this study used a cross-sectional design so factors found to be associated with smoking status are not necessarily causally associated. Third, the methodology of a statewide telephone interview survey, even though conducted in-language, potentially may result in a lower representation of less-acculturated participants compared with the familiarity of an in-person or community-based survey. Although declining response rates have already been observed in statewide tobacco surveys for the general population in California and Massachusetts, there is no evidence that this has resulted in different representation of population subgroups and any less accurate or biased estimates of smoking behavior (Biener, Garrett, Gilpin, Roman, & Currivan, 2004
). In comparison with the California tobacco surveys for other Asian American subgroups that used similar methodology, our study achieved a higher participation rate of eligible contacted participants (63.5%) than the surveys for Chinese Americans (52%) or Korean Americans (48%; Tong, Tang, et al., 2009
With California Vietnamese men continuing to smoke at higher rates than the general population, sustained efforts at targeting and assessing this population for smoking cessation, using culturally and linguistically competent methodologies, remain important. Utilizing a population-based approach with community outreach may be most beneficial since current smokers have low health care access, utilization, and knowledge. Future analyses will further examine smoking cessation behaviors within the Vietnamese American population.