Does Culture or Illness Change a Smoker’s Perspective on Cessation? Iraj M. Poureslami, PhD; Jessica Shum, BA; Natalie Cheng, BA; J. Mark FitzGerald, MD Objectives: To explore cultural context for smoking cessation within Chinese communities in Vancouver, and identify opportunities to support development of culturally appropriate resources for cessation. Methods: Applied participatory approach involving community members, patients, and key-informants in the design and implementation of the research. Results: Whereas many participants were motivated to quit, their perceptions of desire to do so were not supported by ef-

I

n 2011 roughly 5.8 million Canadians smoked,1 and it is estimated that up to 20% of deaths in Canada over the past 10 years can be attributed to smoking,1,2 Tobacco use and indirect exposure to smoke are the most important avoidable risk factors for respiratory and cardiovascular diseases such as chronic lung diseases (eg, asthma, chronic obstructive pulmonary disease (COPD), lung cancer), and ischemic heart disease and hypertension.3-5 Mandarin- and Cantonese-speaking Canadians constitute the largest immigrant group in British Columbia (BC) and Canada.6,7 Their country of origin, China, is the largest consumer of tobacco in the world with 350 million smokers.8-12 Although reported rates of smoking for Chinese men in Canada are far lower at 20% than in China, where up to 60% of adult men smoke,13,14 Chinese-Canadian men have been found to be at a significant risk of excess illness and death from smoking-related illness.14,15 This excess morbidity and mortality suggests that smoking is not recognized as a health risk of concern among recent Chinese imIraj M. Poureslami, Senior Health Evaluation Scientist, University of British Columbia, Division of Respiratory Medicine, Centre for Clinical Epidemiology and Evaluation, Vancouver, BC. Jessica Shum, Research Assistant, University of British Columbia, Division of Respiratory Medicine, Centre for Clinical Epidemiology and Evaluation, Vancouver, BC. Natalie Cheng, Research Assistant, University of British Columbia, Division of Respiratory Medicine, Vancouver, BC.J. Mark FitzGerald, Co-Director, Institute for Heart and Lung Health, University of British Columbia, Professor of Medicine and Head of UBC and VGH Division of Respiratory Medicine. Correspondence Dr FitzGerald; [email protected]

Am J Health Behav.™ 2014;38(5):657-667

fective interventions and many attempts to quit were unsuccessful. Conclusion: Tobacco control clinics and care providers need to adopt culturally and linguistically relevant interventions to facilitate behavioral modifications and cessation in ethnic minority communities. Key words: smoking cessation, participatory research, cultural competence, Chinese communities Am J Health Behav. 2014;38(5):657-667 DOI: http://dx.doi.org/10.5993/AJHB.38.5.3

migrants,16,17 a group likely to face significant linguistic, cultural, and financial barriers to accessing health information and health care services in their new homeland. More than two-thirds (69%) of Chinese-Canadians are foreign-born, and up to 40% of this have been classified as linguistically isolated.18-20 Many Chinese live in ethnically concentrated communities in North America, where Mandarin and Cantonese are spoken almost exclusively; these communities have been targeted by the tobacco industry through use of community media.13,21-23 To counter this targeted marketing and encourage smoking cessation and tobacco-reduction practices among Mandarin- and Cantonese-speaking Canadians, there is a critical need for a community-based approach encompassing both prevention strategies and cessation interventions. Tobacco dependence and a desire to quit are prevalent in all racial and ethnic groups.19,24-27 Studies show that racial minority groups—including African Americans, American Indians/Native Americans, Alaskan Natives, Asian and Pacific Islanders, and Hispanics—have high mortality rates in a number of smoking-related disease categories.28-32 Tobacco-reduction studies have demonstrated the efficacy of a variety of smoking cessation interventions in racial minority populations.8,33-37When considering health interventions, the importance of involving patients and communities in their development and implementation is well documented.28,38,39 However, there have been relatively few systematic studies in Canada examining participatory interventions specifically designed for ethnic minority groups, such as for smoking cessation.3,13,40,41 Community participation enables the

657

Does Culture or Illness Change a Smoker’s Perspective on Cessation? creation of effective counseling and self-help materials, written in the language of preference ,and incorporating key cultural sensibilities.30,42-44 Research indicates that members of ethnic minority groups do best when provided with interventions that are effective, evidence-based, and respectful of their cultural beliefs.11,35,36,45 Whereas physicians should offer treatments identified as effective for all patients,43,46 they also should remain sensitive to individual differences and health beliefs that may affect compliance and success.30,45 Culturally appropriate treatment models, for example, may increase treatment uptake.4,29,31,42 The plan was to conduct a community-based exploratory study to assess attitudes and beliefs about smoking behavior in Cantonese and Mandarin communities. Our intention was to compare the participants’ perspectives about smoking to differentiate knowledge and practice about smoking cessation between men and women, younger and older smokers, and COPD patients who still smoke, and non-patient smokers. We also aimed to identify the community key-informants’ perspective about smoking beliefs and behaviors in the Mandarin and Cantonese communities. Doing so, we invited service providers in the community care centers, representatives of the community organizations serving Chinese communities, and health professionals from the target communities to consult in our qualitative study. Furthermore, COPD patients who still smoked were also of interest to us due to their continuation of smoking despite their smoking induced chronic disease and the rationales behind their continuation of smoking. The goals were 2-fold: the first was to identify reasons why individuals in these communities start smoking and why many do not quit; the second was to discover culturally endorsed means of supporting smoking cessation. Our study objectives were to document the nature of tobacco use within the target communities; to describe the communities’ knowledge, attitudes, and behaviors regarding smoking; to identify which communication approaches were considered appropriate and practical to promote smoking cessation; and to develop knowledge that would be helpful to identify key messages and educational materials best suited to meet the communities’ needs. The ultimate aim was to apply the qualitative data obtained in this study to frame a conceptual model for our current study that we are conducting at the present with the same community in Vancouver, Canada and to use the gained knowledge in developing culturally and linguistically relevant smoking cessation programs for the Chinese community. Therefore, a target sample size was not accounted for in this qualitative behavioral focused research. METHODS The study’s objectives were best met using a community-based participatory research (CBPR) approach.28,40,47,48 CBPR provides a forum for active

658

participation in the research process by members of the communities being studied; this participation is seen as a key input into the development of health programs and interventions targeted at the communities in question.47,49,50 CBPR facilitates community capacity building as well as knowledge translation in support of community-endorsed interventions.28,29,49,51 Members of the Mandarin and Cantonese communities in Metro Vancouver actively contributed to study development and implementation. To get the most benefit from the community involvement, a Community Advisory Council (CAC) was formed, which included smokers from the community, community key-informants, and professionals serving and working with these communities. The CAC provided input and suggestions on developing the focus groups’ and interviews’ questions and involved in the development of the framework for this study. They also trained one male and 3 female bilingual researchers, who were fluent in Mandarin and Cantonese and had English as second language. The training was mainly focused on how to recruit study participants, how to undertake focus groups and personal interviews with smokers from their own communities, and how to conduct the group discussions or individual interviews using a neutral unbiased approach. The community researchers also transcribed and translated focus group and interview data. Furthermore, the research coordinator interviewed key-informants working within these Chinese communities. Participant Recruitment To capture a range of perspectives on smoking behaviors, we identified 3 distinct groups of participants for recruitment: (1) community members who were smokers or ex-smokers; (2) patients who were smokers and had been diagnosed with a smoking-related disease, primarily COPD; and (3) healthcare providers who provided care to members of the target communities. Recruits for Group I consisted of members of Mandarin- or Cantonese-speaking communities within Metro Vancouver. Using a purposive sampling frame, we sought adults (≥21 years old) who were current or former smokers. To be eligible, participants had to be of Chinese descent and be immigrants or children of immigrants. Group II consisted of patients, with the same ethnic background, who were current smokers with a diagnosis of COPD. To capture the care providers’ perspective, Group III comprised of 20 health care professionals who worked in different healthcare settings in the Metro Vancouver area, and serve Mandarin- and Cantonese-speaking communities, including primary care and emergency department physicians, respirologists, community organization educators, and hospital respiratory therapists. Participants for Group I were recruited from within the communities using a variety of methods (eg, posting flyers, referral) applied in previous studies.47,48,52 The

Poureslami et al COPD patients in Group II were recruited directly by Metro Vancouver-based respirologists who were the study collaborators. The healthcare providers were identified and introduced by team members and through network with community agency collaborators. Although a target sample size was not an intention in this qualitative study and we used the purposeful sampling method, we tried to enroll enough participants who met the study criteria of interest in each of the 3 groups. The aim was to include participants who might have wide variations in their knowledge, attitudes, and practices related to smoking and/or had particular knowledge or experience in smoking cessation (eg, patients vs non-patient smokers, professionals vs community members). Considering the fact that numbers of COPD patients who are still currently smoking in this community is low, we were unable to enroll as many COPD patients in the study as we did with the community smokers. Data Collection Data collection for Group I was undertaken through 5 focus group sessions (between 5 to 8 participants in each session, a total of 28 participants) and 15 one-on-one interviews. One-on-one interviews were conducted with participants who were not willing to join the group discussions or were unable to make the focus group sessions but were still interested in contributing to the study. To capture the best information during the group discussions and personal interviews, we used identical questions for both focus group discussions and in-person interviews. Focus group sessions lasted roughly 90 minutes; the interviews were roughly an hour. Data collection for Group II, the COPD patients, occurred during a series of 4 patient-oriented focus group sessions. These sessions were conducted independently of those for Group I, and Group II participants were not interviewed one-onone. Focus group and interview sessions for both groups were conducted at places of convenience for participants: eg, participants’ homes, community centers, and our clinical center. Verbal consent was obtained at time of recruitment and printed consent forms, in the participant’s preferred written language (Chinese Simplified, Chinese Traditional, or English), were signed prior to each focus group or interview session. Honoraria were paid to cover travel and parking expenses. Community researchers conducted the focus group sessions and interviews in Mandarin or Cantonese. Sessions were audio-recorded and transcribed; transcripts then were translated into English. Questions were developed through a review of relevant literature and previous smokingrelated focus group studies with Mandarin and Cantonese asthma and COPD patients,8,12,21,53-55 with input from the CAC. The aim was to ensure the applicability, relevance, and understandability of the questions. Themes included smoking initiation, reasons for continuation, cessation barriers,

Am J Health Behav.™ 2014;38(5):657-667

and community services needed for cessation, as well as strategies to motivate people to quit, in these communities. For Group II (COPD patients) we also included some questions to capture their perceptions and beliefs regarding the link between smoking habits and their COPD. Sessions began with a demographic scan, gathering personal information including language spoken at home, age, ethnicity, educational level, and place of birth. Participants were then asked to describe their smoking habits and history, including any attempts to quit. Personal data also included descriptions of health beliefs and trusted sources of health information. Using a broader cultural lens, the sessions explored participants’ perspectives on why people in their community start smoking, what contributes to success in quitting, and suggestions for a preferred approach for supporting people in their community to quit smoking. Healthcare providers provided consent to participate in the personal interview via e-mail. Each interview lasted approximately 30 minutes and was conducted in English, by the research coordinator. The interviews were either in-person (in the provider’s office) or via the telephone. In 2 cases the interviews were conducted using the Internet (via e-mail). To elicit the healthcare provider perspective, the semi-structured interview guide included the same questions that were asked to Group I participants on issues related to the smoking habits among adults in their communities, and within their patient population. The research coordinator took notes throughout the interviews, which were later reviewed and confirmed by the participants. Data Analysis To identify specific themes, we undertook a 3-step analysis. First, we systematically read the translated transcripts, reviewing the moderators’ notes on the non-verbal content, and comparing and contrasting the responses of the participants within and across groups to document emerging themes. We then established thematic categories, and finally, we sorted responses into each category. The aim was to identify recurring, emergent themes using constant comparison of the interview and focus group transcripts, as well as examination of deviant cases.56-58 The identified themes for the analyses included: reasons for starting smoking, reasons for continuing smoking, motivation to quit, previous quitting attempts, perceived barriers to success, and recommendations for developing smoking cessation programs for Chinese communities. The research coordinator led this analysis, with community researchers and research team members reading portions of transcripts, so a consensus could be reached on the thematic categories. Fieldwork and analysis continued until the team felt saturation had been reached, with no new themes emerging. When initial analyses were complete, we took our findings to a meeting with community workers and immigrant organizations

DOI:

http://dx.doi.org/10.5993/AJHB.38.5.3

659

Does Culture or Illness Change a Smoker’s Perspective on Cessation?

Table 1 Quotes from Participants on Reasons for Starting Smoking Community Members (smokers and ex-smokers) ≤35 year old “A lot of people in my community smoke to socialize. They smoke because their friends smoke.” “Not exactly peer pressure but belief that it is something to do when hanging out with friends.” “When it is exam time, I smoke a lot more.” Community Members (smokers and ex-smokers) >35 year old “Everyone around me smoked when I was young, it was like your appearance looks very high class.” “When I was young, I was surrounded by smokers in the family.” “My husband smoked and I followed him to smoke for fun. When he passed away, I was sad and started smoking on myself [sic], and then got addicted.” “I almost lost my parents in a car accident, so that was a stressful year for me, so it was just natural for me to pick up a cigarette since many family members around me smoked.”

serving Mandarin and Cantonese communities. Feedback from this meeting was used to refine our interpretations. In addition, we elected to stratify the Group I analyses by age. Many studies report different patterns of smoking and smoking cessation practice in younger and older smokers. 20,59-61 Younger adults have demonstrated negative attitudes toward traditional smoking cessation approaches (“cold turkey,” cutting down on their own, self-motivation approach), whereas older smokers have shown less willingness to support cessation attempts with newer aids such as nicotine patches. 34,35,41,62,63 We divided the participants into 2 groups—≤35 years of age and >35 years of age—to explore whether our data supported these differences in perspective. RESULTS There were 90 participants in the study. Group I consisted of 43 community members, both smokers (N = 32) and ex-smokers (N = 11). This group comprised 35 men and 8 women; 26 (60%) were 35 years of age or under. Approximately 26 (60%) of Group I participants spoke Cantonese; the remainder spoke Mandarin. Group II comprised 27 COPD patients (15 men and 12 women). Twenty members (75%) of this group spoke Cantonese. Group III, the healthcare provider key-informant group, consisted of 20 participants, all of whom worked with Mandarin- and Cantonese-speaking communities. Their professional roles included primary care physician, emergency department physician, respirologist (pulmonologist), community organization educator, and hospital respiratory therapist. We interviewed an almost equal number of Mandarin- and Cantonese-speaking health care providers. Group I: Community Members (smokers and ex-smokers) This group described dimensions of their smoking experience, from what prompted them to begin smoking, to what influenced their attempts to quit.

660

Reasons for starting smoking. Younger participants (≤35 years old) identified a variety of triggers to trying their first cigarette, from the influence of friends, to peer pressure, to school or work-related stress. Friends’ influence and peer pressure were described by 14 (56%) of participants as a catalyst, followed by curiosity 8 (31%), cultural/community norms 6 (25%), and school or work-related stress 3 (13%). Older smokers (>35 years old) identified generational community norms as a common reason 4 (25%) to start smoking. There was a generational difference in means of access as well: 11 (43%) of young participants indicated that they got their first cigarette from friends at school or in the community, whereas 6 (36%) of the older smokers got their first cigarettes by stealing it from their father, or receiving it from an older relative. Table 1 lists direct quotes from the participants in Group I on reasons for starting smoking. Reasons for continuing to smoke. Fifteen (60%) of ≤35 year old smokers indicated that the principal reason for continuing to smoke was the social aspect of smoking—along with smoking’s role as a coping strategy for dealing with everyday stresses. One male participant described smoking as a social tool. Many of the young male participants who said they enjoyed smoking when socializing, also indicated that they felt in control of their smoking. Their view was that their smoking was occasional, that they were not addicted, did not affect their health to a significant degree, and would be easy to give up in the future. Some of the female smokers drew on examples of friends or relatives who remained healthy despite smoking. Ten (40%) of younger participants ascribed their ongoing in smoking to it being a habit, and 5 (20%) indicated that the interaction of smoking with other habits (eg, drinking alcohol) was a major reason for continuing to smoke. Among older participants who had smoked for longer periods of time, the principal reasons for continuing to smoke were the beliefs that they were physically addicted to nicotine, that it was too late to quit, that smoking can aid concentration, and/or that it could kill bacteria

Poureslami et al

Table 2 Quotes from Participants on Reasons for Continuing to Smoke Community Members (smokers and ex-smokers) ≤35 year old “For me, smoking is a conversation starter. It helped me to meet new people and make friends because then we have something in common.” “It’s a habit in my life, I’m not addicted.” “I’m a social smoker, unless I’m stressed, I’m not addicted.” Community Members (smokers and ex-smokers) >35 year old “I heard from my friends who were trying to quit that they were constipated because they were used to smoking and having bowel movements at the same time.” “I have a lot of work stress and that was the reason I smoke again after quitting.” “I smoke because of lot [sic] of work stress. I am really scared to quit now. If I quit and I start to smoke again, then it would be a big problem. I would smoke even more. If I smoke one or 2 packs a day then I will die quicker. So I am scared [to quit].” “Smoking can make you concentrate at work. For example, if you are tired or very sleepy, if you smoke…. you will feel better.” “People telling me ‘don’t smoke’ and I said I am a businessperson, I need to think of new things. I have a lot of things to think about.” “Once you cut down on the number of cigarettes or quit smoking, illnesses will start creeping up, punctured lungs or other illnesses.” COPD Patients (smokers) “I would like to say that smoking is a very very bad habit but I just can’t stop smoking at the minute. I am enjoying myself too much, because my body needs the nicotine.” “I smoke because I am bored, it is my habit, and I want to avoid my stomach become [sic] big.”

and germs. One participant felt that smoking aided with digestive regularity. Two male smokers mentioned work stress as the main reason for continuing. Many older smokers indicated that continuing smoking, despite awareness of health risks, was preferable to suffering from withdrawal symptoms. Table 2 highlights quotes of findings in this regard. Motivation to quit. Many participants wanted to quit, and those who did gave interrelated explanations for why they wanted to do so. Five major reasons to quit were: (1) fear of developing a chronic illness; (2) having a chronic cough and not wanting it to worsen; (3) anxiety about smoking too much when it is not healthy; (4) public bans on smoking and awkwardness around friends who do not smoke; and (5) the expense. A male smoker, for example, cited family as a reason to quit smoking: “I quit because my wife does not smoke and I have a daughter, they help me quit—I would think of her and would want to not smoke.” Twelve young male smokers (75%) mentioned maintaining good exercise capacity

as a major motivator to quit. Three young female smokers (40%) cited 2 principal motivators to quit, the “prospect of having a baby in the future” and “pressure from family members.” Conversely, some younger participants indicated that formal attempts at dissuasion including education, advertising, and cautionary warnings on cigarette packages did not serve as motivators. Health, however, was principal consideration for older smokers, 11 (67%) whom mentioned health-related issues as a key reason to quit. In addition, some participants had suffered conditions (eg, COPD or heart disease) that they thought were caused by smoking. These individuals reported being motivated to quit; yet, whereas some had stopped smoking on the advice of their doctor, many had failed to act on this advice. Comments made by participants on motivation to quit can be found in Table 3. Attempts to quit. Some participants expressed a desire to quit and achieve a healthier lifestyle. Informal methods of quitting such as ‘‘cutting down,’’ “cold turkey,” and “using will power” were the most

Table 3 Quotes from Participants on Motivation to Quit Community Members (smokers and ex-smokers) >35 year old “I want to quit because my family members are all saying that I stink.” “I know the health reasons in smoking. So I want to quit for my health. My dad was a smoker too so he passed away with cancer. So basically I am looking out for my family.” “I really want to quit but which method do I use to quit? I never get enough information from my doctor, and then… the only way is to depend on yourself for quitting smoking.”

Am J Health Behav.™ 2014;38(5):657-667

DOI:

http://dx.doi.org/10.5993/AJHB.38.5.3

661

Does Culture or Illness Change a Smoker’s Perspective on Cessation?

Table 4 Quotes from Participants on Attempts to Quit Community Members (smokers and ex-smokers) >35 year old “I tried to quit 3 times before and I have failed all 3 times. I think a video clip developed by a professional team [in my own language] is a good idea to keep and watch at home particularly if a doctor talks about ways to quit smoking.” “I smoke and there is no way for me to quit smoking but I would like to learn some tips of how to quit.” “Regarding the issue about quitting smoking, I will listen to doctor’s statistics and advice.”

common approaches. Although many participants indicated that they had tried to quit on at least one occasion, few had been successful and most relapsed within days or even hours. Those who had been successful tended to be admired and respected in their family and community and were seen as strong and highly motivated. In addition, many young participants said they would like to adopt a healthier lifestyle and quit, if they had access to trusted counseling services and methods that had been proven effective. For older smokers (>35), professionally developed materials and counseling were mentioned as aids to help them quit smoking. Table 4 provides a summary of quotes on attempts to quit. Perceived barriers to success. Younger participants’ perceptions about barriers to quitting included being tempted by others to smoke. Others felt that smoking was a habit, but not an addiction—that they could stop anytime and have no problem quitting. Participants also cited everyday stresses and withdrawal symptoms as impediments to successful cessation. Participants in the older group described failed attempts with aids such as nicotine patches, gum, and tablets. Older participants also reported poor experiences seeking advice from healthcare providers. Family doctors were not viewed as accessible sources for advice on quitting for either the younger or older smokers, although family doctors were one of the sources the older participants (in particular those with chronic problems) listened to, when they decided to quit smoking. Most older participants said they would quit if they could see how smoking has affected their health (eg, a scan of their lungs, a test result), or if their doctor told them they had to or else they would die. Personal evidence seemed important: “I need to see an actual image of my lungs showing the damage done from smoking. Not some other person’s lung—seeing a generic black lung of a 10-year smoker will not have an effect on me. I need to see that my own lungs have become black, then I will for sure quit smoking.” Additional comments made by participants are summarized in Table 5. Recommendations. Almost all the young participants indicated that education alone is not enough to motivate people to quit. In the words of a male participant: “Education is NOT effective in getting people in our age group to quit. Because we’ve heard it all—how smoking is bad for you,

662

how it’s killing you slowly, etc. But it’s tough to correlate that to our own health because we are not seeing the detrimental effects to our health right now.” Some of the younger participants also spoke to the influence of mass media, noting that as long as smoking remained “cool” it was going to be difficult to encourage young people to either not start at all, or quit. Older participants expressed a desire for more culturally sensitive strategies to support smoking cessation. Roughly half of the older participants indicated that they felt they would be able to quit smoking if they received information from a doctor or pharmacist who spoke their language and was able to explain to them why they should stop. Group II: COPD Patients (smokers) This group shared perspectives as patients experiencing a smoking-related disease (COPD). Although their reflections covered some of the same aspects of the smoking experience as Group I, they also focused more specifically on the negative health effects associated with their tobacco use. Eighteen (68%) of the participants in this group indicated that smoking held no benefits. Reasons for continuing to smoke. Although these participants did not focus on why they started smoking, there were comments about why they persisted in doing so. Three patients explained that smoking helped in social situations, saying they believed it helped them make friends, and they perceived smoking as having an entertainment value. A few participants had some misconceptions about smoking. As with some of the Group I participants, one patient believed smoking could kill bacteria and germs “...that’s what people used to tell [me].”More participants’ quotes are shown in Table 2. Disadvantages of smoking. Some patients in this group expressed a belief that there was no disadvantage to smoking, citing people in their community who smoked and lived to be 90. A male patient said: “There are examples of 100-year-olds still smoking. Those people are still here on earth smoking 2 packs a day.” The majority 21 (87%), however, when asked about the downside of smoking, described the negative consequences of smoking in terms of lung disease (eg, COPD, cough/ mucus, airway problems, lungs turning black, lung cancer). One patient was concerned about his fingers turning yellow from holding cigarettes; 2

Poureslami et al

Table 5 Quotes from Participants on Perceived Barriers to Success Community Members (smokers and ex-smokers) ≤35 year old “Yes, I tried [to give up smoking] once and the success lasted only 2 weeks . . . friends offered me a cigarette. I took one. I said oh right—I didn’t care.” “A popular reason why they [people in my age group] don’t want to quit would be because they don’t feel the effect on their body.” “The patch or nicotine gum does not work for me.” COPD Patients (smokers) “...the last time I was telling my doctor I was trying to give up he said ‘good luck.’ That’s what he said, nothing else... he didn’t give me a pamphlet or information to tell me the best way to quit and where I can get advice.”

female participants believed that their fingernails turned black because of smoking. A male patient mentioned his concern about the effect smoking might have on his mouth and teeth. Similarly, a female patient indicated that her mouth gets bitter when she smoked and this worried her. Two other female patients felt that they smelled badly and “stink” when they smoke. Sixteen (60%) of this group believed that cigarettes cause disease and that smokers often feel weak and suffer from poor health. This awareness prompted some participants, despite their own habit, to avoid exposure to smoking outside of home, to walk away from secondhand smoke, or to stay away from people who smoke. They also asked friends and relatives to not smoke while visiting their home. Conversely, a few patients mentioned they only came to realize disadvantages after they quit. A male patient said: “As soon as I quit, my symptoms got worse.” Another male patient reported that: “My body needs the nicotine.” Many other COPD patients who still smoke raised this point. Beyond the risk to themselves, 4 patients mentioned concerns that their smoking would harm others at home and damage the environment. A minority of 6 patients (25%) also mentioned the issue of cost. A female COPD patient said: “I quit because cigarettes are expensive. It was too expensive.” Perceived barriers to success. Some participants had attempted to quit on the advice of their doctor, although many were critical of their family physician’s response when they raised their desire to quit. The main barriers to successful smoking cessation, as cited by the patients, were the communication and language issues with healthcare providers that prevented their understanding of the information provided. Some felt their family doctor was a poor or inappropriate source of advice. As with participants in Group I, some patients expressed a desire to have a doctor or pharmacist who could speak their language and convince them to quit smoking, and a few participants had received help from such providers. Generally speaking, however, the most commonly cited barrier to helping these participants quit was a perceived lack of time spent by their healthcare

providers giving advice, and providing counseling and other means of support for smoking cessation. Others noted being unable to find appropriate counseling services—because of time constraints, unfamiliarity with healthcare provider, and/or language or cultural barriers. They also expressed a need for more culturally sensitive strategies to support smoking cessation in their community. Table 5 illustrates participants’ comments on perceived barriers to success.

Am J Health Behav.™ 2014;38(5):657-667

DOI:

Group III: The Healthcare Providers The input from the healthcare providers dealt with barriers to the successful support of their patients who smoked. Some professionals described cultural barriers to the uptake of health promotion messages about smoking cessation, pointing out that many of their Chinese patients do not believe in a personal susceptibility to smoking-related illnesses. In addition, they felt many patients were not particularly willing to take control of their health, and that young patients often did not prioritize quitting. The key-informants confirmed that smoking plays an important role in these communities, confirming findings that offering up and sharing cigarettes is seen as a means of enhancing friendships.28,30,64 Most professionals felt they needed more training on how to deliver effective smoking cessation services that would address the general and cultural barriers to smoking cessation. They pointed to the need for the development and validation of culturally appropriate education tools that could be integrated into their practice to support cessation and self-management of smoking-related diseases. Many providers, however, also pointed out that the volume of their practice meant that time constraints rendered such training out of reach. They felt training opportunities were scarce, and only a few providers were aware of any local smoking cessation service tailored for ethnic minority groups. There was a general sense among these informants that the challenges associated with the smoking-related burden of disease in new immigrant communities were such that developing appropriate tools for prevention of uptake and sup-

http://dx.doi.org/10.5993/AJHB.38.5.3

663

Does Culture or Illness Change a Smoker’s Perspective on Cessation? port for cessation should be a policy priority for health decision makers in British Columbia. DISCUSSION Research has shown that smoking is deeply embedded in social interactions in the Chinese community.9,27,54,55 Offering cigarettes has been a longstanding custom to enhance personal friendship and relationships.4,28,30,64 The tradition of exchanging cigarettes as a gesture of goodwill is indicative of the level of tobacco’s integration in Chinese culture.31,63,65 As revealed by our study participants, this places a large burden on self-efficacy for quitting, and avoiding temptations to slip within a prosmoking social environment. This socio-cultural context should be considered when developing targeted smoking cessation strategies for Mandarinand Cantonese-speaking communities. Other social and cultural factors associated with increased smoking rates also have been identified in Canadian-Chinese communities, in particular among women, adolescents and young adults.23,38,45,66 For example, the power of smoking as a social symbol and a facilitator to social interaction was borne out in our study, especially among younger participants. When discussing why they started smoking, the most commonly cited reason by participants was influence of friends and peer pressure. Smoking was described as a conversation starter; it eased social situations and helped to meet new people and make friends. Smoking provided these participants with something in common with other people in social situations—giving them something to do together when “hanging out,” especially at parties or in clubs. The older participants also spoke to the culturally normative—and ubiquitous—presence of smoking as an influence on their initial uptake of tobacco, whereas some COPD patients cited smoking’s social and “entertainment” value as reasons for continuing to smoke, despite their illness. Stress caused by migration, school, and work have been associated with smoking initiation.4,66 Our study participants spoke about these stresses as both triggers for uptake and as key reasons for persisting with smoking despite awareness of health risks. Interestingly, both younger and older participants indicated that stress was the major reason for starting to smoke, and coping with daily stress was the main reason cited by many participants for continuing to do so. One woman indicated that: “I cannot quit because stress come out [sic] and then I feel I want to smoke.” For older participants, initiation of smoking was associated with daily stress and continuing smoking was related to pain relief and coping with emotional issues. Although many participants spoke about being unable to quit because of the challenges associated with addiction, other rationales were also offered up for continuing. Some participants persisted in smoking because they were not convinced of its

664

harmful influence on health. Pointing to examples of people who smoked and lived into old age, young participants underscored the disconnection associated with smoking’s delayed effects: not “feel[ing] the effect on their body.” This, in combination with examples of people who apparently suffered no ill effects after a lifetime of smoking, lowered motivation to quit. Others spoke to beliefs in the beneficial effect of smoking, whether it was to assist their digestion or to kill germs. Motivation to quit was reasonably high among younger participants. Young men in this study were interested in building and maintaining fitness, and young women talked about wanting to quit before having children. Generally, participants who wanted to quit spoke of health concerns, financial implications, and pressure from family and friends as influential to their desire to do so. Health concerns were of particular concern amongst older smokers. There were, however, many identified barriers to success. Younger smokers spoke of being tempted by other smokers; needing tobacco to deal with stresses from work, school, and family; and reluctance or inability to deal with withdrawal symptoms. Older smokers described struggles with a longstanding addiction, as well as lack of appropriate support in primary care. Participants generally did not view their family doctor as someone to go to for advice on quitting, feeling that the doctor’s role was predominantly to treat illness. The COPD patients added that they felt there was insufficient time in their medical appointments with their doctors to receive the counseling and education they felt necessary to support their efforts to quit. To close these gaps in support, COPD patients in this study indicated that they would quit if they had access to culturally appropriate smoking cessation resources and services. They sought out trusted advisors within their own communities—who understood their language, culture, and context. They also pointed out that the glamorization of smoking is often reinforced by advertising and marketing in local media. An important recommendation made by the smokers in Group I was to change the image of smoking—making it appear less socially acceptable might prevent young people from starting to smoke in the first place. The interviews with healthcare professionals provided another lens on smoking in these communities. There was general consensus among these informants that smoking rates in these communities constituted a health issue that needed attention from health policy decision makers. In the meantime, these providers identified a range of interrelated and reinforcing barriers to effective smoking cessation in Mandarin- and Cantonese-speaking communities. These included language barriers (eg, difficulties accessing linguistically and culturally appropriate smoking cessation programs); barriers arising from cultural beliefs associated with smoking; attitudinal problems (eg, their perception that few Chinese men felt quitting smoking

Poureslami et al was a priority); and finally, lack of adequate time and resources to ensure that all family physicians received proper training in culturally appropriate smoking cessation practices. Possible Implications of the Findings Despite the small sample size, we believe the findings of our exploratory study suggest an action plan to be taken by healthcare decision makers in Metro Vancouver to consider culturally and linguistically appropriate approaches in their attempts to promote smoking cessation in the Chinese community. This is a more relevant argument when we consider the fact that Chinese are the number one immigrant community in Metro Vancouver, Canada, and North America, and also smoking is highly prevalent in this community.1,6,12,30,31,65 Such an action is that healthcare providers receive cultural competency smoking cessation training so they are able to bring a cultural sensibility to their consultations with ethnic minority patients. It will help them to understand the health beliefs of their patients about smoking better and apply such understanding in their consultations regarding smoking cessation. Research plays a critical role in identifying and testing practical smoking cessation interventions. Exploratory studies like ours lay the foundation for the development and piloting of culturally specific interventions. One such intervention could be to identify external motives and work to empower smokers to self-manage their feelings (by promoting some self-rewarded stimulus), and testing the implications of combined external and internal factors, while considering socio-cultural factors, on smoking cessation. The strength of communal health beliefs and cultural norms revealed in this study highlight the inherent opportunities in developing community-level interventions to complement individual level interventions. Creating ways to involve smokers and community members in research, and the development and testing of culturally appropriate interventions and means of knowledge dissemination should be a priority to this end. This project will offer further opportunity to involve community members as peer researchers and advocates, increasing community capacity, and creating local change agents. We expect this increased community capacity will contribute to community empowerment and the engagement of community members in making a healthier society. Future research on the impact of health literacy on smoking should target high-risk groups within these communities. Young female smokers, for example, could be considered a vulnerable/high-risk group, and targeted prevention programs might benefit from sex-specific educational interventions.

community, the findings would be useful in some instances. Given the strong dimension of community participation through the CPBR study design and the breadth of input received from community members, professionals, and key-informants, we believe that our findings may be applicable in the development of smoking cessation programs for Mandarin- and Cantonese-speaking communities in Metro Vancouver. As the result, we applied the knowledge we gained from this study in our current research within the same community to develop smoking cessation interventions that are culturally and linguistically relevant, and also scientifically appropriate.

Limitations A major limitation of this study was the small sample size. However, as the intention of this study was not to generalize the findings to larger Chinese

Conclusion With a relative dearth of research on the beliefs, attitudes, perceptions, and behaviors of Mandarin- and Cantonese-speaking smokers in Canada about smoking and its cessation, this study set out to explore these perspectives from 3 distinct groups: community members who were smokers or ex-smokers; patients with COPD who were current smokers; and healthcare providers working with these communities. Our goals were to gain an understanding of the cultural context for smoking and smoking cessation within Mandarin- and Cantonese-speaking communities in Metro Vancouver, and to identify opportunities to support the development of culturally appropriate resources for smoking prevention and cessation. Deepening our understanding of the phenomena of smoking and smoking cessation in these communities will help inform development of much needed culturally appropriate interventions. In conclusion, it is likely that perceived health consequences, particularly for younger smokers, and availability and accessibility of culturally and linguistically appropriate smoking cessation materials, specifically developed for older adults, would be associated with seeking help to quit smoking, with no indications for detrimental effects in other outcome parameters. This would in itself already be enough reason for recommending enhancing awareness re smoking-related health consequences via community and media involvement, as well as development of culturally relevant smoking cessation education/counseling programs. However, because of heterogeneity in participant groups, study populations, nature of the study, and outcome measures, data are still insufficient to formulate clear recommendations regarding the form and contents of smoking cessation programs for Chinese smokers. Therefore, it is necessary to conduct more research with a larger sample size with consecutive follow-ups to assess why Mandarin- and Cantonese-speaking communities continue to smoke and to identify the major systemic and cultural-relevant barriers for their participation in smoking cessation programs. Furthermore, to overcome these barriers, community leaders and health policy decision makers need to: (1) craft culturally appropriate responses;

Am J Health Behav.™ 2014;38(5):657-667

DOI:

http://dx.doi.org/10.5993/AJHB.38.5.3

665

Does Culture or Illness Change a Smoker’s Perspective on Cessation? (2) change messaging in mass media; (3) develop culturally and linguistically appropriate cessation aids; and (4) train healthcare providers that work in these communities. Human Subjects Statement The Institutional Review Board of the University of British Columbia approved the focus group and interview process, and all participants gave their written consent to participate in the group discussion and individual interviews. Conflict of Interest Statement We declare that there is no conflict of interest in terms of ownership of shares, consultancy, speaker’s honoraria or research grants from commercial companies or professional or governmental organizations with an interest in the topic of the paper. Acknowledgments This project was funded by an unrestricted educational grant from Centre for Lung Health at University of British Columbia, Vancouver. References

 1. Statistics Canada. Health at a glance. Current smoking trends. Available at: http://www.statcan.gc.ca/pub/82624-x/2012001/article/11676-eng.htm#n1. Accessed September 7, 2013.  2. Jones A, Gulbis A, Baker EH. Differences in tobacco use between Canada and the United States. Int J Public Health. 2010;55(3):167-175.  3. Baliunas D, Patra J, Rehm J, et al. Smoking-attributable mortality and expected years of life lost in Canada 2002: conclusions for prevention and policy. Chronic Dis Can. 2007;27(4):154-162.  4. Beardall S, Edwards N. Social and cultural determinants of smoking behavior in selected immigrant groups: results of key informant interviews. Fam Community Health. 1995;18(2):65-72.  5. Canadian Lung Association. Making Quit Happen: Canada’s challenges to smoking cessation. Available at: http://www.bc.lung.ca/smoking_and_tobacco/smoking_cessation.html. Accessed June 1, 2013.  6. Statistics Canada. 2008. Some facts about the demographic and ethnocultural composition of the population. Available at: http://www.statcan.gc.ca/pub/91003-x/2007001/4129904-eng.htm#2. Accessed July 8, 2013.  7. Statistics Canada. Canada at a glance. Population. Available at: http://www.statcan.gc.ca/pub/12581-x/2012000/pop-eng.htm#t01. Accessed July 8, 2013.  8. Burton D, Zeng XX, Chiu CH, et al. A phone-counseling smoking-cessation intervention for male Chinese restaurant workers. J Community Health. 2010;35(6):579-585.  9. Gu D, Kelly TN, Wu X, et al. Mortality attributable to smoking in China. N Engl J Med. 2009;360(2):150-159. 10. Wakefield MA, Durkin S, Spittal MJ, et al. Impact of tobacco control policies and mass media campaigns on monthly adult smoking prevalence. Am J Public Health. 2008;98(8):1443-1450. 11. Wong C, Tsoh J, Tong E, et al. The Chinese community smoking cessation project: a community sensitive intervention trial. J Community Health. 2008;33(6):363-373. 12. Yu X, Xiao D, Li B, et al. Evaluation of the Chinese versions of the Minnesota nicotine withdrawal scale and the

666

questionnaire on smoking urges-brief. Nicotine Tob Res. 2010;12(6):630-634. 13. Chen W. Susceptibility to Smoking among Chinese-Canadian Non-smoking Adolescents. Doctoral Dissertation. Vancouver, BC: University of British Columbia; 2008. Available at: https://circle.ubc.ca/bitstream/ handle/2429/942/ubc_2008_fall_chen_weihong. pdf?sequence=1. Accessed September 5, 2013. 14. Gallup World.2012. Three in 10 Chinese adults smoke. Available at: http://www.gallup.com/poll/152546/ three-chinese-adults-smoke.aspx. Accessed September 2, 2013. 15. Gupta M, Brister S, Verma S. Is South Asian ethnicity an independent cardiovascular risk factor? Can J Cardiol. 2006;22(3):193-197. 16. Ho S, Lam T, Fielding R, Janus E. Smoking and perceived health in Hong Kong Chinese. Soc Sci Med. 2003;57(9):1761-1770. 17. Yang J, Hammond D, Driezen P, et al. Health knowledge and perception of risks among Chinese smokers and non-smokers: findings from the Wave 1 ITC China Survey. Tob Control. 2010;19(Suppl 2):i18-i23. 18. BCStats. Tobacco attitudes and behaviors survey report. Available at: http://www.bcstats.gov.bc.ca/StatisticsBySubject/SocialStatistics/OtherSocialStatistics.aspx. Accessed June 2, 2013. 19. British Columbia Ministry of Health. Smoking cessation program. Available at: http://www.health.gov.bc.ca/ pharmacare/stop-smoking/. Accessed June 2, 2013. 20. Solberg L, Boyle RG, McCarty M, et al. Young adult smokers: are they different? Am J Managed Care. 2007 13(11):626-632. 21. Li L, Yong HH, Borland R, et al. Reported awareness of tobacco advertising and promotion in China compared to Thailand, Australia and the USA. Tob Control. 2009;18(3):222-227. 22. Pollay RW. Targeting tactics in selling smoke: youthful aspects of 20th century cigarette advertising. J Marketing Theory Pract. 1995;3(1):1-22. 23. Pollay RW. Targeting youth and concerned smokers: evidence from Canadian tobacco industry documents. Tob Control. 2000;9(2):136-147. 24. British Columbia Ministry of Health. B.C. rolls out program to help smokers quit. Available at: http://www2.news.gov.bc.ca/news_releases_20092013/2011PREM0117-001206.htm. Accessed June 2, 2013. 25. British Columbia Ministry of Health. Helping people quit smoking. Available at: http://www.health.gov.bc.ca/tobacco/cessation.html. Accessed June 2, 2013. 26. The British Columbia Lung Association. Smoking & tobacco cessation. Available at: http://www.bc.lung.ca/ smoking_and_tobacco/smoking_and_tobacco.html. Accessed June 1, 2013. 27. Yang T, Fisher KJ, Li F, Danaher BG. Attitudes to smoking cessation and triggers to relapse among Chinese male smokers. BMC Public Health. 2006;6:65. 28. Burton D, Fahs M, Chang JL, et al. Community-based participatory research on smoking cessation among Chinese Americans in Flushing, Queens, New York City. J Interprofessional Care. 2004;18(4):443-445. 29. Deason LM, Adhikari SB, Clopton TM, et al. The Ohio cross-cultural tobacco control alliance: understanding and eliminating tobacco-related disparities through the integration of science, practice, and policy. Am J Public Health. 2010;100(Suppl 1):S240-S245. 30. Ferketich AK, Wewers ME, Kwong K, et al. Smoking cessation interventions among Chinese Americans: the role of families, physicians, and the media. Nicotine & Tob Res. 2004;6(2):241-248. 31. Fu S, Ma G, Tu X, et al. Cigarette smoking among Chinese Americans and the influence of linguistic accultura-

Poureslami et al tion. Nicotine & Tob Res. 2003;5(6):803-811. 32. Novotny TE, Mamudu HM. 2008. Progression of tobacco control policies: lessons from the United States and implications for global action. Health, Nutrition and Population (HNP) Discussion Paper. Available at: http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627-1095698140167/NovotnyPoliticalEconomy.pdf. Accessed June 1, 2013. 33. Grossman E, Sherman S.Telling smokers their “lung age” promoted successful smoking cessation. Evidencebased Med. 2008;13(4):104. 34. Okuyemi KS, Nollen NL, Ahluwalia, JS. Interventions to facilitate smoking cessation. Am Fam Physician. 2006;74(2):262-271. 35. Reus VI, Smith BJ. Multimodal techniques for smoking cessation: a review of their efficacy and utilisation and clinical practice guidelines. Int J Clin Pract. 2008;62(11):1753-1768. 36. Shelley D, Nguyen N, Peng C, et al. Increasing access to evidence-based smoking cessation treatment: effectiveness of a free nicotine patch program among Chinese immigrants. J Immigr Minor Health. 2010;12(2):198-205. 37. Steptoe A, Kerry S, Rink E, Hilton S.The impact of behavioral counseling on stage of change in fat intake, physical activity, and cigarette smoking in adults at increased risk of coronary heart disease. Am J Public Health. 2001;91(2):265-269. 38. Poureslami I, Nimmon L, Doyle-Waters, et al. Effectiveness of educational interventions on asthma self-management in Punjabi and Chinese asthma patients: a randomized controlled trial. J Asthma. 2012;49(5):542-551. doi: 10.3109/02770903.2012.682125. 39. Shelley D, Fahs MRY, Das DNN, et al. Effectiveness of tobacco control among Chinese Americans: a comparative analysis of policy approaches versus community-based programs. Prev Med. 2008;47(5):530-536. 40. Health Canada. 2010. Canadian Tobacco Use Monitoring Survey (CTUMS) 2010. Available at: http://www.hcsc.gc.ca/hc-ps/tobac-tabac/research-recherche/stat/ ctums-esutc_2010_graph-eng.php. Accessed June 2, 2013. 41. Wang ZJ, Ramcharan S, Love EJ. Cancer mortality of Chinese in Canada. Int J Epidemiol. 1989;18(1):17-21. 42. Hermalin AI, Lowry D.2010. The age prevalence of smoking among Chinese women: a case of arrested diffusion? Available at: http://www.psc.isr.umich.edu/pubs/pdf/ rr10-718.pdf. Accessed June 2, 2013. 43. Huang CL.Evaluating the program of a smoking cessation support group for adult smokers: a longitudinal pilot study. J Nurs Res. 2005;13(3):197-205. 44. May R, Tofler GH, Bartrop R, et al. Smoking cessation through a novel behavior modification technique. Am J Cardiol. 2010;106(1):44-46. 45. McCready J. A Report on Survey of the Public, Physicians, Pharmacists and Work Places. Ontario Smoking Cessation Initiative: A Process Evaluation Report. Toronto: Centre for Health Promotion; 2001 46. Sallis JF, Hill RD, Killen JD, et al. Efficacy of self-help behavior modification materials in smoking cessation. Am J Prev Med. 1986;2(6):342-344. 47. Poureslami I, Doyle-Waters MMR, Nimmon L, et al. Hearing the community voice: methodological issues in developing asthma self-management educational materials for immigrant communities. In Agyemang C, Airhihenbuwa CO, de-Graft Aikins A (eds.), Ethnicity: Theories, International Perspectives and Challenges. Hauppage NY: Nova Publishers 2014:125-156. 48. Poureslami I, Rootman I, Doyle-Water MMR, et al. Health

literacy, language, and ethnicity-related factors in newcomer asthma patients to Canada: a qualitative study. J Immigr Minor Health. 2011;13(2):315-322. 49. Faridi Z, Grunbaum JA, Gray BS, et al. 2007. Community-based participatory research: necessary next steps. Prev Chronic Dis. Available at: http://www.cdc.gov/pcd/ issues/2007/jul/06_0182.htm. Accessed June 2, 2013. 50. Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-based research: assessing partnership approaches to improve public health. Annu Rev Public Health. 1998;19:173-202. 51. Poureslami I, Nimmon L, Doyle-Waters MMR, FitzGerald JM. Using community-based participatory research (CBPR) with ethno-cultural groups as a tool to develop culturally and linguistically appropriate asthma educational material. Diversity in Health Care. 2011;8(4):203215. 52. Klassen AF, Gulati S, Watt L, et al. Immigrant to Canada, newcomer to childhood cancer: a qualitative study of challenges faced by immigrant parents. Psychooncology. 2012;21(5):558-562. 53. Ho MG, Ma S, Cha IW, et al. Smoking among rural and urban young women in China. Tob Control. 2010;19(1):1318. 54. Wong C, Tong E, Tsoh J, et al. Patterns of tobacco-use behavior among Chinese smokers with medical conditions. J Community Health. 2009;34(6):472-479. 55. Xu F, Yin X, Zhang M, et al. Prevalence of physician-diagnosed COPD and its association with smoking among urban and rural residents in regional mainland China. Chest. 2005;128(4):2818-2823. 56. Thompson B, Thompson LA, Thompson J, et al. Heavy smokers: a qualitative analysis of attitudes and beliefs concerning cessation and continued smoking. Nicotine & Tob Res. 2003;5(6):923-933 57. Eklund BM, Nilsson S, Hedman L, Lindberg I. Why do smokers diagnosed with COPD not quit smoking? - a qualitative study. Tob Induced Dis. 2012;10(17):1-7. 58. Gierisch JA, Straits-Tröster K, Calhoun PS, Acheson S, et al. Tobacco use among Iraq- and Afghanistan-era veterans: a qualitative study of barriers, facilitators, and treatment preferences. Prev Chronic Dis. 2012;9(110127):1-8. 59. Haddock C, Lando H, Klesges R, et al. Modified tobacco use and lifestyle change in risk-reducing beliefs about smoking. Am J Prev Med. 2004;27(1): 35-41. 60. Hines D. Young smokers’ attitudes about methods for quitting smoking: barriers and benefits to using assisted methods. Addict Behav. 1996; 21(4):531-535. 61. Osypuk TL, Kawachi I, Subramanian SV, Acevedo-Garcia D. Are state patterns of smoking different for different racial/ethnic groups? An application of multilevel analysis. Public Health Rep. 2006;121(5):563-577. 62. Hu SS, Pallonen UE, Meshack AF. The impact of immigration status on tobacco use among Chinese-American adults in Texas. J Immigr Minor Health. 2010;12(2):206214. 63. Shelley D, Fahs M, Scheinmann R, et al. Acculturation and tobacco use among Chinese Americans. Am J Public Health. 2004;94(2):300-307. 64. Zhang J, Ou JX, Bai CX.Tobacco smoking in China: prevalence, disease burden, challenges and future strategies. Respirology. 2011;16(8):1165-1172. 65. Thridandam M, Fong W, Jang M, et al. A tobacco and alcohol use profile of San Francisco’s Chinese community. J Drug Educ. 1998;28(4):377-393. 66. Stoll K. Correlates and predictors of tobacco use among immigrant and refugee youth in a Western Canadian city. J Immigr Minor Health. 2008;10(6):567-574.

Am J Health Behav.™ 2014;38(5):657-667

DOI:

http://dx.doi.org/10.5993/AJHB.38.5.3

667

Copyright of American Journal of Health Behavior is the property of PNG Publications and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.