Individual and family factors associated with intention to quit among male Vietnamese American smokers: Implications for intervention development
Research Highlights
►33% of Vietnamese male smokers in California had no intention to quit smoking. ►Higher education was associated with no intention to quit in Vietnamese men. ►Recent quit attempts with or without assistance was associated with quit intention. ►Intention to quit was associated with experiencing smoking-related family conflicts. ►Interventions should support smokers' needs at both individual and family levels.
Introduction
Despite declining smoking prevalence in the general U.S. population (Centers for Disease Control and Prevention, 2009), and among Asian men from 2002 to 2006 in selected U.S. communities, smoking prevalence remained higher among non-English speaking Vietnamese men than the general population (Liao et al., 2010). In two studies, Vietnamese men had the highest smoking prevalence (29.5% and 35.4%) among Asian Americans (California Health Interview Survey, 2008, Chae et al., 2006). Our 2008 California Vietnamese Adult Tobacco Use Survey (CVATUS), the first statewide population-based survey conducted in both Vietnamese and English, reported a current smoking prevalence of 25% among males and < 1% among females (Tong et al., 2010).
Vietnamese Americans are at high risk for smoking due to sociodemographic factors consistently correlated with higher smoking, including lower acculturation, limited English proficiency, and lower educational attainment (An et al., 2008, Chae et al., 2006, Kim et al., 2007, Tang et al., 2005). Half of the Vietnamese American population immigrated after 1990, with 88% speaking Vietnamese at home and 55% speaking English less than “very well” (U.S. Census Bureau, 2007). Compared to all other Asian ethnic groups, they have the fewest (70%) high school graduates, and the second highest (14%) poverty rate (U.S. Census Bureau, 2007). Likely, additional contributing factors specific to this community include low level of knowledge about smoking-related health risks (Ma et al., 2005, Ma et al., 2003), high social acceptability of smoking (Chan et al., 2007), the continuing influx of immigrants from Vietnam where male smoking prevalence is high (42% in 2008) (World Health Organization, 2008), and low quit intention. Large scale surveys among Vietnamese American smokers showed that 52% to 76% were in “precontemplation” indicating no intention to quit smoking in the next 6 months (Chan et al., 2007, Wiecha et al., 1998). Thus, effective strategies to promote smoking cessation among Vietnamese American men should address their low intention to quit, which is associated with high smoking prevalence across populations (Etter, 2004, Thyrian et al., 2008) and poor smoking cessation outcomes (Haug et al., 2010).
Evidence-based interventions targeting Asian American smokers are lacking (Chen and Tang, 2007, Fiore et al., 2008, Kim et al., 2007, Ranney et al., 2006). To date, only five published controlled trials specifically target Asian Americans; they include two community-based media-led interventions targeting Vietnamese (Jenkins et al., 1997, McPhee et al., 1995), one program utilizing lay health worker outreach targeting Southeast Asian men (Chen, 2001), one testing a single session counseling intervention with nicotine replacement targeting Chinese and Korean American smokers (Fang et al., 2006), and one using individual motivational interviewing and nicotine replacement targeting Chinese Americans (Wu et al., 2009). Among the 3 studies with Vietnamese Americans, only one 3-year community-based media campaign intervention demonstrated a significant treatment effect with lower smoking prevalence in the intervention community compared to the control community (Jenkins et al., 1997).
Empirical evidence underscores the strengths of the Transtheoretical Model of Change (TTM) (DiClemente et al., 1991, Prochaska and Velicer, 1997) when tailoring interventions by stages of change for smokers in community and clinical settings, including non-English speaking Asian smokers (Haug et al., 2010, Velicer et al., 2006, Wu et al., 2009). The TTM is a promising intervention framework to promote smoking cessation among Vietnamese American men by addressing their low intention to quit (Chan et al., 2007, Wiecha et al., 1998). However, some researchers criticize TTM's heavy emphasis of individual determinants with little consideration of social or familial factors (Glanz and Bishop, 2010, Koshy et al., 2010) found to be associated with intention to quit smoking (Myung et al., 2010, Wiecha et al., 1998) and smoking cessation outcomes among Asian American smokers (Spigner, Yip, Huang, & Tu, 2007).
The family is central to health behaviors for Asian Americans (Kagawa-Singer and Blackhall, 2001, McPhee, 2002, Nilchaikovit et al., 1993). Perceived encouragement from family was described as the most helpful facilitator for cessation among Chinese and Vietnamese Americans (Spigner et al., 2007). Significantly more calls are made to the Asian-language California Smokers' Helpline from smokers' family and friends (“proxy calls”) as compared to the English-language Helpline (40% vs. 6%) (Zhu, Anderson, Johnson, Tedeschi, & Roeseler, 2000). This unique “proxy call” phenomenon observed among Asian-language speakers highlights the potential significance of family involvement in smoking cessation.
How family factors influence intention to quit smoking or the smoking cessation process among Asians remains unclear. Vietnamese American male smokers who intended to quit were more likely to report that their family was upset about their smoking than those with no intention to quit (Wiecha et al., 1998). Among Korean American male smokers, intention to quit was associated with self-reported smoking restrictions at home, ranging from complete prohibition (“smoking ban”) to some limitations (Myung et al., 2010). In China, an educational intervention delivered to mothers of sick children led to smoking cessation at 3 months among fathers who smoked (Chan, Leung, Wong, & Lam, 2008). Being married predicted both smoking abstinence and reduction among motivated smokers in China (Sun et al., 2009).
No study to date has used multivariate techniques to examine both individual and family factors simultaneously in their associations with quit intentions in Vietnamese American male smokers. Using the population-based data from the 2008 CVATUS and the intention component of the stages of change construct from TTM as a framework, this study examined correlates of quit intentions, including both individual factors (demographics, smoking intensity, nicotine dependence, and previous quit attempt experience) and family factors (marital status, children in household, home smoking ban, and report of smoking-related family conflicts), in order to identify new approaches to smoking cessation interventions among Vietnamese American smokers.
Section snippets
Data source description
The CVATUS was a statewide computer-assisted telephone interview survey conducted in Vietnamese and English of 1101 Vietnamese men and 1078 Vietnamese women in California in 2007–2008. Details about the survey and sampling are reported elsewhere (Tong et al., 2010). In brief, a list of the 55 most common Vietnamese surnames (Lauderdale and Kestenbaum, 2000, Swallen et al., 1998, Taylor et al., 2009) was used to provide a random sample of 13,000 numbers from all residential telephone landline
Sample characteristics
Table 1 shows the characteristics at the individual and family levels of the study sample (n = 234) by intention to quit smoking. Most participants (86%) completed the interview in Vietnamese. More than 70% were married and had children in their household. Over 90% reported a smoking ban at home; about 40% reported that smoking had caused conflicts in the family. A majority (78%) smoked daily in the last month; nearly half (46.6%) smoked < 10 cigarettes on the days smoked and 63% smoked within 60
Discussion
This population-based study showed that one-third of Vietnamese male smokers in California never intend to quit smoking and that half were in “precontemplation,” with no intention to quit in the next 6 months. This is much greater than California smokers in general who are in “precontemplation” (25%) (California Department of Public Health California Tobacco Control Program, 2008). Given low smoking prevalence in California (Centers for Disease Control and Prevention, 2009, Messer et al., 2007),
Conclusions
This study identified significant correlates at both the individual and family levels of quit intention among Vietnamese male smokers. For Vietnamese male smokers with low motivation to quit, encouraging even short-term quit attempts and involving the family are potential strategies to promote intention to quit. For Vietnamese male smokers who are motivated to quit, promising interventions may include enabling smokers to make use of lessons learned from previous quit attempts, facilitating use
Role of Funding Sources
Research for and preparation of this manuscript was supported by the California Department of Public Health, Tobacco Control Program Grant 06-55563. The investigators also received support from the Asian American Network for Cancer Awareness, Research and Training through the National Cancer Institute Cooperative Agreement U01/CA114640. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the views of any of the funding agencies. Funding
Contributors
Dr. Tsoh conceived the current study design, and drafted the manuscript. Dr. Gildengorin conducted data analyses. Drs. Tsoh, Tong, Gildengorin, Nguyen, Modayil and McPhee, and Mr. Wong participated in data collection, data interpretation, provided critical revisions and final approval of the manuscript. Dr. McPhee was the Principal Investigator of the study providing the data source for the current study.
Conflict of Interest
All other authors declare that they have no conflicts of interest.
Acknowledgments
Research for and preparation of this manuscript was supported by the California Department of Public Health, Tobacco Control Program Grant 06-55563 and the Asian American Network for Cancer Awareness, Research and Training through the National Cancer Institute Cooperative Agreement U01/CA114640. We would like to acknowledge Caroline Kurtz for her leadership in launching this survey.
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