Objective: Asian American immigrants experience high rates of cigarette smoking. A community based survey was conducted to understand the smoking behaviours, knowledge, and attitudes of restaurant workers in Boston's Chinatown.
Design: Cross sectional survey in Chinese of a convenience sample of 54 restaurant workers recruited through extensive outreach activities.
Results: All 54 of the workers were male immigrants. 45 (83.3%) reported smoking cigarettes regularly, and the remaining nine were former smokers. 36 of the smokers (80.0%) started smoking before entering the USA. The workers were aware that cigarettes are addictive (98.1%), cause lung cancer (79.6%), and lead to heart disease (64.8%). However, a substantial number reported that smoking was relaxing (75.9%) and enhanced concentration (66.7%). Nearly half believed low tar and low nicotine cigarettes to be safer than standard brands. The vast majority of workers believed that smoking was not socially acceptable for women. Smokers reported they received information on quitting most commonly from friends (60%), newspapers (53.5%), and television (44.4%). The restaurant workers most often saw advertising against smoking in Chinese newspapers (63%).
Conclusion: Despite high rates of smoking, Chinese American restaurant workers were generally aware of the health risks and were interested in quitting. Community based research can set the stage for targeted public health efforts to reduce smoking in immigrant communities.
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Maximising tobacco control for Asian Americans requires a special understanding of immigrant populations. While 14.2% of all Asian Americans and Pacific Islanders smoke nationally,1 this rate is substantially higher among the recently arrived. In Massachusetts, foreign born Asian American men are more than three times more likely to smoke than Asian Americans born in the US,2 and the smoking prevalence in immigrant communities can exceed 50%.3
One reason for such extensive tobacco use among immigrants may be that smoking has become an integral part of Asian male culture. Nearly two of every three adult men in China are smokers.4 Moreover, after arrival in the USA, these immigrants are unlikely to benefit from public health efforts based in American culture and values, even when they are translated to their native languages. To date, there has been little success in establishing outreach to such groups to assess their health needs.
To begin to address this problem, the Massachusetts Department of Public Health launched a pilot study to assess the smoking knowledge, behaviours, and attitudes of immigrant restaurant workers in Boston's Chinatown. Restaurant workers represent a special public health target population for many reasons. Firstly, they represent a large segment of the workforce in Chinatown. Secondly, virtually all primarily speak Chinese and most lack the ability to speak English well. Thirdly, most are men. Fourthly, if Chinese restaurant employees could quit smoking in large numbers and commit to a non-smoking environment for their workplaces, it could lead to radical change for the entire Chinese American community. No previous studies have reported on smoking behaviours in an urban Chinatown or among immigrant restaurant workers.
In this pilot study, the Department of Public Health contracted with researchers from the Chinatown based South Cove Community Health Center to develop a Chinese language survey tool to collect data on tobacco use, coordinate outreach efforts with area community groups and businesses, and interview the workers. We hypothesised that the restaurant workers would have little knowledge of the adverse effects of smoking and little exposure to anti-smoking messages and resources.
We conducted a cross sectional survey of tobacco use and attitudes in a convenience sample of 54 restaurant workers in Chinatown during May and June of 2000.
Boston's Chinatown spans an approximately 9 × 10 block area near the city's downtown area, and is home to an estimated 5000 people,5 many of who are Chinese speaking immigrants. In this congested area, nearly every block contains a restaurant. According to its business association, Boston's Chinatown was home to 46 restaurants, employing an estimated 750 people, in November 1999 (R Moy, vice president of the Board of Chinatown Business Association, personal communication, 4 November 1999).
The first step in developing the survey was determining whether any English or Chinese language survey was currently in use to assess smoking in Chinatown. A medical literature search and an informal survey of 20 community agencies did not find any such instrument. To address this need, we developed a survey that included (but was not limited to) questions from two standardised instruments, the Massachusetts Behavioral Risk Factor Surveillance System and the Massachusetts Adult Tobacco Survey. The final survey covered current and past smoking, knowledge and attitudes about cigarettes, and exposure to public health efforts. The questions were translated into Chinese by a licensed translator with expertise in health issues, and then back translated into English to assess accuracy. The two translators and Dr Lam resolved discrepancies. A focus group was then conducted of 10 restaurant workers to discuss the effectiveness and cultural appropriateness of the questionnaire. Modifications were made based on the feedback elicited from the focus group participants.
Dr Lam and other senior staff at the South Cove Community Health Center (SCCHC) discussed possible methods for recruitment of subjects and decided on a strategy that proceeded along three parallel tracks. Firstly, we posted flyers in Chinese in 20 Chinatown service agencies. The flyers invited male workers interested in participating in a study on tobacco use to call a phone number at SCCHC and schedule an interview. The decision to recruit only males was based on the belief that the vast majority of restaurant workers are male and that it was unlikely this pilot effort could attract sufficient females to enable a stratified analysis by sex. Secondly, we collaborated with five community agencies to recruit subjects from among their client population. Thirdly, working with restaurant owners, we actively sought subjects in all of the major Chinatown restaurants. An implementation plan was developed which allowed six weeks for recruitment of subjects. Since we did not know initially how successful we would be in attracting restaurant workers to participate, a modest goal of 40 subjects was put forth. Ultimately, 54 male restaurant workers volunteered by the deadline date and were interviewed for the study. All volunteers were accepted for participation in the study and there were no refusals. Fifty four workers represent approximately 7% of the estimated restaurant workforce. While a larger sample size would have been more desirable, further recruitment of subjects was limited by time and resources.
Interviews were conducted in person in either Cantonese or Mandarin. The respondent was provided with a copy of the questionnaire to read as the questions were being asked. Interviews lasted approximately 30 minutes. A $15 stipend was given for participation. The study was approved by the human subjects review board of the Massachusetts Department of Public Health.
Survey results were compiled and tabulated using EpiInfo, Version 6.04b. Further analysis was performed in Microsoft Excel 97. After reviewing the data, we compared our sample to comparison populations surveyed by the Massachusetts Behavioral Risk Factor Surveillance System and the Massachusetts Adult Tobacco Survey. These comparisons are described in the discussion section. Proportions were compared by χ2 testing with all p values for two tailed tests.
We surveyed 54 ethnically Chinese restaurant workers. All were male. Fifty one (94.4%) spoke primarily Chinese at home. All were immigrants, with 43 (79.6%) born in China. Almost two thirds (64.9%) of the workers had been in the USA for less than 10 years (table 1).
Of the 54 restaurant workers, 45 described themselves as current smokers (83.3%) and the remaining nine (16.7%) as former smokers (with all nine having quit at least six months previously). They had begun to smoke as early as age 7 and as late as 31 years old. Marlboro was the most frequently smoked brand of cigarettes (70.1%). Forty five ever smokers (83.3%) and 36 current smokers (80.0%) started smoking before entering the USA (table 2).
Thirty six (83.7%) of the smokers intentionally quit smoking for one day or longer in the past 12 months. Of these, 16 (44.4%) used smoking cessation products such as nicotine gum or the nicotine patch. Five of the study subjects have used “traditional herbs, foods or medicines” to stop smoking. Thirty one (68.8%) of the smokers said they were thinking about quitting in the next six months.
While 11 smokers (24.4%) reported that smoking was allowed throughout their home, 15 (33.3%) reported limitations on where or when they smoked at home, and 18 reported that smoking was not allowed in the home at all (40%).
Smoking related beliefs
Most of the restaurant workers surveyed understood the adverse effects of smoking. All 54 agreed with the statement that smoking harms the health of children who inhale second hand smoke; 53 (98.1%) felt that smoking is physically addictive; 45 (83.3%) felt that smoking caused lung cancer in non-smokers; 43 (79.6%) believed that smoking caused lung cancer in smokers; 42 believed (77.8%) that a smoker's health improves upon stopping smoking, and 35 (64.8%) felt that smoking increases the risk of heart disease.
Some restaurant workers also believed there were benefits to smoking, including that it helps people relax (41 subjects, 75.9%), enhances concentration (36 subjects, 66.7%) and helps control weight (18 subjects, 33.3%). Twenty six participants (48.1%) agreed with the statement that smoking low tar and low nicotine cigarettes carries less risk of illness than smoking standard cigarettes; 28 (51.9%) disagreed. Beliefs about low tar and low nicotine cigarettes were not associated with the type of cigarette smoked.
The workers' attitudes on the acceptability of smoking for males differed from their views on the acceptability of smoking for females. While 51 (94.4%) thought smoking was not socially acceptable for teenage girls, 41 (75.5%) thought it unacceptable for teenage boys (p < 0.01). Even more dramatically, while 40 (74.1%) thought smoking socially unacceptable for adult women, only 18 (33.3%) thought it unacceptable for adult men (p < 0.01).
The overwhelming majority of participants supported restrictions on indoor smoking. Twenty five (46.3%) said that smoking should not be allowed indoors at all and an equal number said that smoking should be allowed indoors only in designated areas, compared to 3 (5.6%) who did not believe in any restrictions.
Exposure to public health efforts
A significant majority of restaurant workers reported receiving information to help quit smoking and public health information against smoking in the last 12 months (table 3). Among the nine smokers, information on quitting was more commonly received from friends and relatives (60.0%) than from such public health efforts as a smoker's quitline (4.4%) or doctor's office (37.8%). The most common source of information against smoking was Chinese newspapers (63.0%). Over half of participants (53.7%) reported seeing a television message against smoking in the last 12 months.
According to US government's Healthy People 2010, which sets as a goal the elimination of ethnic disparities in health, “Asians and Pacific Islanders, on average, have indicators of being one of the healthiest population groups in the United States”. However, the report also states, “There is great diversity within this population group, and health disparities for some specific segments are quite marked”.6 The present study describes one particularly high risk segment within the Asian American community. Given the difficulty in reaching restaurant workers in Chinatown, and the fact that their smoking behaviour has never been studied previously, we believe the results provide a unique window into the challenge of tobacco control for Asian Americans. Such a perspective is critically important to future public health efforts; according to the recent US Census, the number of Asian Pacific Islanders in Massachusetts grew by 67.8% from 1990 to 2000, the largest percentage increase among all ethnic groups in the state.7
After a literature review and survey of community agencies found no available survey instrument, we developed and tested a Chinese language questionnaire to assess smoking behaviour and beliefs. This instrument was extensively focus group tested to ensure cultural sensitivity and appropriateness. Then, after extensive collaboration with community agencies and business leaders in Boston's Chinatown, we recruited restaurant workers to be surveyed. We found that more than four in five smoke cigarettes. This level of prevalence is consistent with research demonstrating remarkably high rates of smoking among men in Asian countries4,8 and with previously reported studies of Asian-American immigrants.
The study has several limitations. The sample was not random and the total number of respondents was small. Therefore, these findings may not be generalisable. It is possible, for example, that workers who were current or past smokers were preferentially referred or preferentially interested in the study.
The data suggest three challenges to reaching this population. Firstly, the majority of restaurant workers began to smoke before entering the USA, making primary prevention efforts largely irrelevant. The fact that more than half of the workers smoke Marlboros—the most popular international brand—also indicates their smoking patterns may be set before immigration.
Secondly, the restaurant workers have limited exposure to public sources of information on cessation services. Substantially fewer smokers in our study (44.4%) received information on quitting from television than did male smokers in Massachusetts overall (88.3%), according to data from the 1998–1999 Massachusetts Behavioral Risk Factor Surveillance System (Massachusetts Department of Public Health, unpublished data). Disparities for information obtained from radio (22.2% for our sample v 55.8% for all male smokers), billboards (17.8% v 50.6%), printed brochures (37.8% v 54.1%), and the statewide telephone quitline (4.4% v 9.6%) were also quite large. Less formal sources on quitting did not show impressive disparities, including newspapers and magazines (53.3% v 62.3%), workplace (24.4% v 31.3%), and friends/relatives (60.0% v 66.2%). We suspect that one major reason for the difference between informal and formal sources of information is that many of the formal sources (television, radio, and billboards) are not produced in Chinese. Callers to the quitline, however, can discuss smoking cessation with counsellors through the use of translators.
Thirdly, statewide data suggest that the restaurant workers were less knowledgeable about some aspects of smoking than Asian Americans generally. For example, substantially more study subjects (48.1%) mistakenly believed low tar cigarettes to be safer than standard cigarettes than did all Asian American men in Massachusetts (29.2%) surveyed from 1994 to 1999 through the Massachusetts Behavioral Risk Factor Surveillance System (Massachusetts Department of Public Health, unpublished data). One reason may be decreased exposure to educational campaigns. Compared to all Asian Americans surveyed in the 1998 Massachusetts Adult Tobacco Survey (MATS), substantially fewer restaurant workers had heard advertising against smoking in the last 12 months on radio (14.8% v 37.9%) or had seen advertising on billboards (29.6% v 46.2%). Rates of exposure to anti-tobacco messages on television were approximately the same between the two groups (53.7% v 58.2%). Given that MATS was performed in 1998, a full two years before the current survey, changes in the Massachusetts anti-tobacco campaign and other temporal factors may explain some of these observed differences.
In addition to elucidating these barriers to smoking cessation, the study also identifies several potential strengths related to tobacco use. Firstly, the restaurant workers are not ignorant of the dangers of smoking, with the vast majority recognising that smoking posed risks to their own health and the health of those around them. This knowledge stands in stark contrast to smokers surveyed in China, only 36% of whom believed smoking can cause lung cancer and only 4% of whom associated cigarettes with heart disease.4 Secondly, many of the smokers in our study already accepted limitations on the use of cigarettes; two out of five reported that cigarette use was not allowed at home. Thirdly, nearly two thirds of workers received information on smoking from Chinese newspapers. Fourthly, most believed that youth smoking was socially unacceptable. Finally, virtually all subjects supported restrictions on indoor smoking, which could have long term future ramifications for creating smokefree restaurants and public places in Chinatown.
What this paper adds
Smoking rates in the USA among Asian Americans are lower than the national average, but prevalence estimates in Massachusetts show that foreign born Asian American men are more than three times more likely to smoke than US born Asian Americans. Smoking is an integral part of Asian male culture as evidenced by prevalence surveys in China which show that nearly two of every three adult men are smokers. Given the nearly 70% increase in Asian Pacific Islanders in Massachusetts since the last dicennial census, a comprehensive statewide tobacco cessation strategy needs to include effective interventions targeted to foreign born Asian Americans. No previous studies have reported on smoking behaviours in an urban Chinatown or among immigrant restaurant workers.
This pilot study surveyed 54 restaurant workers in person in either Cantonese or Mandarin regarding their current and past smoking behaviours, knowledge and attitudes about cigarettes, and exposure to public health efforts. Three challenges to reaching this population emerged from the findings. Firstly, the majority of restaurant workers began to smoke before entering the USA, making primary prevention efforts largely irrelevant. Secondly, compared to other male smokers across the state, the restaurant workers have limited exposure to public sources of information on cessation services. Thirdly, while the restaurant workers are not ignorant of the dangers of smoking, with the vast majority recognising that smoking posed risks to their own health and the health of those around them, they were less knowledgeable about some aspects of smoking compared to Asian Americans in general, such as their mistaken belief that low tar cigarettes are safer than standard cigarettes.
The results thus suggest that an effective anti-smoking campaign in Chinatown should go beyond traditional English language efforts, utilise Chinese newspapers, and build upon existing cultural attitudes (such as the belief smoking is inappropriate for women and young people) and knowledge (such as health risks) about smoking. Particular attention should be paid to differences between recent and past immigrants, an important issue that our sample size was not large enough to address. Community health care providers are important allies in developing such a campaign as well as reinforcing to their clients the importance of smoking cessation programmes. Targeted campaigns in Asian American immigrant communities, including a Chinese language quit line, have had some success in California.9–11 These reports, and ours, illustrate that immigrant Asian American smokers respond to well focused efforts to reach them.
In Massachusetts, efforts are underway to build on the current project and develop programmes to reach smokers in Chinatown. The SCCHC, for example, has developed a monthly health promotion programme specifically targeted at restaurant workers. The Chinese language survey, initially created for research purposes, is useful to clinicians who would like to assess the smoking behaviours and attitudes of their patients. The Department of Public Health will make it available for use by others around the world. In his report on smoking among ethnic minorities, the US Surgeon General noted, “[P]rograms must recognize that cultural groups—whether they are based on race/ethnicity, national origin, or other characteristics—are not monolithic entities”.1 As this pilot study demonstrates, public health departments must penetrate behind national summary statistics to fight smoking one community at a time.
This research was supported by a grant from the Massachusetts Tobacco Control Program. The authors also wish to thank research assistants Su Yu Chen, Yu Ting Guan, Ida Kwong, Jenny Lee, Ruheng Long, Flora Wu, and Angel Yuen. Patricia Mona Eng and Hong Vuong provided assistance with the initial development of this effort. Rebecca Wong, MPH, assisted with the conception and design of the study, and Lisa Goldberg reviewed a draft of the article and provided necessary background materials. Finally, the authors thank all of the businesses, community agencies, and restaurant workers who participated in the project.
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