Tobacco use and dependence in Asian Americans: a review of the literature

Racial/ethnic differences in the acute effects of reduced nicotine content cigarettes among adolescents who smoke

OBJECTIVE

Reducing the nicotine content in cigarettes decreases their addictiveness and abuse liability, including among adolescents. Whether these effects differ by race/ethnicity is unknown. This study is a secondary analysis of previously published data collected between 2014-2017. We examined racial/ethnic differences in the effects of smoking cigarettes with varying nicotine content levels on subjective effects and tobacco withdrawal among adolescents who smoke daily.

METHODS

Across two counterbalanced sessions, 50 adolescents recruited from Rhode Island (ages 15-19; 30 % Underrepresented Minorities [URM], 20 % Asians and Pacific Islanders [API]; 50 % Non-Hispanic Whites) self-administered a very low nicotine content (VLNC; 0.4 mg nicotine/g of tobacco) or normal nicotine content control (NNC; 15.8 mg/g) research cigarette following overnight abstinence. Subjective effects were reported post-administration and tobacco withdrawal outcomes were calculated from pre- to post-administration scores. Multilevel linear models tested main and interactive effects between cigarette nicotine content and race/ethnicity on all study outcomes.

RESULTS

Participants reported lower positive subjective effects and reductions in smoking urges after smoking a VLNC cigarette relative to smoking an NNC cigarette (ps < 0.01). A main effect of race/ethnicity emerged, such that API (vs. URM and White) adolescents reported lower positive subjective effects, greater craving reduction, and higher cigarette aversion after smoking, regardless of nicotine content (ps < 0.05). Significant interactions were found between race/ethnicity and nicotine content for cigarette aversion, such that API adolescents rated VLNC (vs. NNC) cigarettes as less aversive than White and URM adolescents did (p = 0.03).

CONCLUSIONS

Findings provide evidence that VLNC cigarettes may reduce abuse liability and tobacco withdrawal symptoms for adolescents across racial/ethnic groups and particularly for API youth.

The efficacy and acceptability of pharmacological monotherapies and e-cigarette on smoking cessation: a systemic review and network meta-analysis

Background and aims

Several pharmacological interventions, such as nicotine replacement therapy (NRT), varenicline, and bupropion, have been approved for clinical use of smoking cessation. E-cigarettes (EC) are increasingly explored by many RCTs for their potentiality in smoking cessation. In addition, some RCTs are attempting to explore new drugs for smoking cessation, such as cytisine. This network meta-analysis (NMA) aims to investigate how these drugs and e-cigarettes compare regarding their efficacy and acceptability.

Materials and methods

This systematic review and NMA searched all clinical studies on smoking cessation using pharmacological monotherapies or e-cigarettes published from January 2011 to May 2022 using MEDLINE, COCHRANE Library, and PsychINFO databases. NRTs were divided into transdermal (TDN) and oronasal nicotine (ONN) by administrative routes, thus 7 network nodes were set up for direct and indirect comparison. Two different indicators measured the efficacy: prevalent and continuous smoking abstinence. The drop-out rates measured the acceptability.

Results

The final 40 clinical studies included in this study comprised 77 study cohorts and 25,889 participants. Varenicline is more effective intervention to assist in smoking cessation during 16-32 weeks follow-up, and is very likely to prompt dropout. Cytisine shows more effectiveness in continuous smoking cessation but may also lead to dropout. E-cigarettes and oronasal nicotine are more effective than no treatment in encouraging prevalent abstinence, but least likely to prompt dropout. Finally, transdermal nicotine delivery is more effective than no treatment in continuous abstinence, with neither significant effect on prevalent abstinence nor dropout rate.

Conclusion

This review suggested and agreed that Varenicline, Cytisine and transdermal nicotine delivery, as smoking cessation intervention, have advantages and disadvantages. However, we had to have reservations about e-cigarettes as a way to quit smoking in adolescents.

Turning the Health Equity Lens to Diversity in Asian American Health Profiles

The monolithic misrepresentation of Asian American (AsAm) populations has maintained assumptions that AsAm people are not burdened by health disparities and social and economic inequities. However, the story is more nuanced. We critically review AsAm health research to present knowledge of AsAm health profiles from the past two decades and present findings and opportunities across three topical domains: (a) general descriptive knowledge, (b) factors affecting health care uptake, and (c) effective interventions. Much of the literature emphasized underutilization of health care services; low knowledge and awareness among AsAms about health-related risk factors, prevention, diagnosis, and treatment; inadequate efforts by health systems to improve language access, provider-patient communication, and trust; and the critical roles of community- and faith-based organizations and leaders in health promotion initiatives. Future opportunities for AsAm health research will require adoption of and significant investment in community-engaged research infrastructure to increase representation, funding, and research innovation for AsAm communities.

Smoking Cessation Interventions Among Asian Americans: a Scoping Review

BACKGROUND

Tobacco use is the leading cause of morbidity and mortality in the USA, with smoking rates remaining disproportionately high among Asian-Americans, particularly in males with limited English proficiency, including Vietnamese (43%), Korean (37%), and Chinese (29%) Americans. Barriers to smoking cessation in this population include high social acceptability of smoking in participants' countries of origin, low quit intention, and limited use of linguistically appropriate smoking cessation resources. This paper aims to conduct a systematic review of studies evaluating the effectiveness of smoking cessation interventions targeting Asian-Americans.

METHODS

The researchers conducted a thorough search of Scopus, Medline, Cochrane Central, and Google Scholar from 2006 through March 2022, as well as reference lists of relevant articles. The inclusion criteria for the studies were that they described smoking cessation interventions for Asian-Americans and Asian immigrants, and reported outcomes related to feasibility, acceptability, usability, and smoking-related outcomes.

RESULTS

The review identified 14 studies with a total of 5607 participants, with participant numbers ranging from 26 to 2277. The interventions varied across 14 distinct approaches, with individual counseling being a prominent component. These interventions were found to be feasible and culturally acceptable. All studies reported positive smoking-related outcomes, including abstinence rates ranging from 26.7 to 68% and an increase in quit attempts. Culturally sensitive components and linguistically tailored content played a significant role in promoting participant engagement. The retention rates in the studies ranged from 42 to 100%, highlighting the importance of partnership with the Asian community, cultural and ethnic congruence, and family involvement and support.

CONCLUSION

The review highlighted the lack of direct in-language treatment as a disadvantage for Asian-American smokers in accessing evidence-based treatments. Despite this, the review reported the feasibility, acceptability, and effectiveness of a limited number of culturally targeted interventions for Asian-Americans, who are the fastest-growing racial-ethnic group. Future research should focus on exploring novel community-based and culturally adapted approaches for hard-to-reach and high-risk ethnic Asian subgroups to further improve smoking cessation outcomes in this population.

A self-administered questionnaire to measure Chinese smokers' cigarette dependence

A self-administered questionnaire for screening cigarette dependence was developed based on a set of 6335 Chinese adult smokers (termed the China Cigarette Dependence Test, CCDT). Both a 20-item version (CCDT-20) and a 7-item of the questionnaire (CCDT-7) were developed following 2-round of tests on their construct validity, test-retest reliability and internal consistency, covering seven dimensions (cigarettes per day, tolerance, withdrawal symptoms, craving, loss of control, regularity, and stereotypy). The results showed that the CCDT-20 and CCDT-7 scores were higher in daily smokers than in occasional smokers, and both were associated with self-rated nicotine dependence, exhaled carbon monoxide (CO), saliva cotinine, and DSM-V. The CCDT-20 and CCDT-7 scales were found to be easier to use by smokers in China and provided a more reliable measure of their cigarette dependence.

Family Support and Readiness to Consider Smoking Cessation among Chinese and Vietnamese American Male Smokers

Introduction

Smoking prevalence is disproportionately high among Asian American immigrant men with limited English proficiency. Understanding the role of family support may provide insights on culturally acceptable strategies to promote smoking cessation.

Aims

This study examined how family support was associated with readiness to consider smoking cessation among Chinese and Vietnamese American male daily smokers.

Methods

We analyzed baseline data (N=340) from a cluster randomized trial of a family-based healthy lifestyle intervention. We assessed the frequency of receiving family support in various forms (encouraging use of cessation resources; praising efforts; checking-in; reminding of familial role). Multiple regression analysis was used to determine associations between family support areas and readiness to consider smoking cessation, controlling for covariates.

Results/Findings

Reporting a higher frequency of receiving praise and encouragement for one's efforts to quit was positively associated with readiness to consider cessation. Other areas of family support were not significant.

Conclusions

These findings provide evidence to explore specific areas of family support in enhancing Asian American smokers' readiness to consider cessation. As there is high interest from Asian American family members to support their smokers for quitting, culturally specific and acceptable strategies are needed to promote smoking cessation among Asian Americans.

Examining the Role of Acculturation in E-Cigarette Use among U.S. Immigrant Adults

Evidence suggests that as immigrants' length of residence in the host country increases, they may integrate their behavior and norms to align with the new community's cultural norms. The current study examined e-cigarette use among immigrants in the U.S., and whether the length of residence in the U.S. is associated with e-cigarette use among immigrants compared to the native-born population. Data were drawn from the 2014/15 and 2018/19 Tobacco Use Supplement to the Current Population Survey. Multivariable logistic regression was used to compare differences in e-cigarette use between native-born populations and immigrants, when immigrants' length of residence in the U.S. was considered. Among immigrants, the prevalence of ever and current e-cigarette use increased significantly from 2.5% and 0.5% in 2014/2015 to 3.2% and 0.8% in 2018/2019, respectively. Multivariable analysis showed that immigrants had significantly lower odds of ever e-cigarette use compared to the mainland-born citizen (0-5 years in the U.S., adjusted Odds Ratio (aOR) 0.57, 95% Confidence Interval (CI) 0.46-0.69; 6-10 years, aOR 0.51, 95% CI 0.41-0.63; 11-20 years, aOR 0.45, 95% CI 0.39-0.53; 20+years, aOR 0.68, 95% CI 0.62-0.76). Similar results were found for current e-cigarette use, with immigrants being less likely to be current users. Findings that e-cigarette use among all immigrants-regardless of years living in the U.S.-was consistently lower than among the native-born population run contrary to the notion that as length of stay increases, health behaviors between immigrants and native populations of the host country become similar.

Association of the Time to First Cigarette and the Prevalence of Chronic Respiratory Diseases in Chinese Elderly Population

BACKGROUND

Increasing number of studies has suggested the time to first cigarette after waking (TTFC) have significant positive effect on respiratory diseases. However, few of them are focused on Chinese population. This study aims to estimate the impact of TTFC on the prevalence of chronic respiratory diseases (CRD) in Chinese elderly and explore the association in different sub-populations.

METHODS

Cross-sectional data of demographic characteristics, living environment, smoking-related variables, and CRD were drawn from the Chinese Longitudinal Healthy Longevity Survey in 2018. Multivariate stepwise logistic regression analyses were conducted to examine the association of the TTFC with the prevalence of CRD.

RESULTS

This study includes 13208 subjects aged 52 years and older, with a mean age of 85.3 years. Of them, 3779 participants are ex- or current smokers (44.9% had the TTFC ≤30 minutes, 55.1% >30 minutes) and 1503 have suffered from CRD. Compared with non-smokers, participants with TTFC ≤30 minutes seemed to have higher prevalence of CRD (OR 1.97; 95% CI, 1.65-2.35) than those with TTFC >30 minutes (OR 1.70; 95% CI, 1.44-2.00), although the difference was statistically insignificant (P_interaction=0.12). Compared with TTFC >30 minutes, TTFC ≤30 minutes could drive a higher prevalence of CRD among female participants, those aged 90 years and older, urban residents, and those ex-smokers (P_interaction<0.05).

CONCLUSIONS

Shorter TTFC relates to higher prevalences of CRD in Chinese older females, those aged 90 years and older, urban residents, and ex-smokers. Delaying TTFC might particially reduce its detrimental impact on respiratory disease in these specific subpopulations.

Evaluation of the Asian Smokers' Quitline: A Centralized Service for a Dispersed Population

INTRODUCTION

Asian immigrants to the U.S. smoke at higher rates than U.S.-born Asians. However, few programs exist to help these immigrants quit and little is known about their real-world effectiveness. The Centers for Disease Control and Prevention funded the Asian Smokers' Quitline to serve Chinese, Korean, and Vietnamese immigrants nationwide. This study examines service utilization and outcomes from the first 7 years of the program.

METHODS

From August 2012 to July 2019, the Asian Smokers' Quitline enrolled 14,073 Chinese-, Korean-, and Vietnamese-speaking smokers. Service utilization rates and cessation outcomes were compared with those of an earlier trial (conducted 2004-2008) that demonstrated the efficacy of an Asian-language telephone counseling protocol. Data were analyzed in 2019.

RESULTS

Asian Smokers' Quitline participants came from all 50 states and the District of Columbia. The main referral sources were Asian-language newspapers (37.2%), family and friends (16.4%), healthcare providers (11.9%), and radio (11.9%). Overall, 37.6% were uninsured, 38.8% had chronic health conditions, and 15.4% had mental health conditions. Compared with participants in the earlier trial, Quitline participants received 1 fewer counseling session (3.8 vs 4.9, p<0.001) but were more likely to use pharmacotherapy (73.6% vs 20.9%, p<0.001). More than 90% were satisfied with the services they received. Six-month prolonged abstinence rates were higher in the Quitline than in the trial (complete case analysis: 28.6% vs 20.0%, p<0.001; intention-to-treat analysis: 20.5% vs 16.4%, p=0.005).

CONCLUSIONS

The Asian Smokers' Quitline was utilized by >14,000 Asian-language-speaking smokers across the U.S. in its first 7 years. This quitline could serve as a model for delivering other behavioral services to geographically dispersed linguistic minority populations.

Determining Optimal Cutoffs for Exhaled Carbon Monoxide and Salivary Cotinine to Identify Smokers among Korean Americans in a Smoking Cessation Clinical Trial

Introduction

It is critical to accurately identify individuals who continue to smoke even after treatment, as this may prompt the use of more intensive and effective treatment strategies to help them attain complete abstinence.

Aims

This study examined optimal cutoffs for exhaled carbon monoxide (CO) and salivary cotinine to identify smokers among Korean Americans in a smoking cessation clinical trial.

Methods

CO and cotinine were measured three to four times over 12 months from the quit day. Statistical analysis was conducted using Receiver Operating Characteristic (ROC) curves.

Results

A CO cutoff of 5 parts per million provided robust sensitivity (80.8-98.3%) and perfect specificity (100%), and a salivary cotinine cutoff of level 2 (30-100 ng/ml) provided the best sensitivity (91.2-95.6%) and perfect specificity (100%). Using these cutoffs, the agreement between self-reports and the two biomarkers ranged from 88.6% to 97.7%. The areas under ROC curves (AUCs) of exhaled CO ranged from 0.90 to 0.99, all of which were significant (all p values < 0.001), and the AUCs of salivary cotinine ranged from 0.96 to 0.98 (all p values < 0.001).

Conclusion

Exhaled CO and salivary cotinine are complementary, and they should be used together to verify smoking abstinence for smokers in a clinical trial.

Acculturation and Exposure to Secondhand Smoke in the Home Among Vietnamese Immigrants in Metropolitan Atlanta

This study represents the first effort to examine associations between various measures of acculturation and past 30-day secondhand smoke (SHS) exposure among Vietnamese-Americans in metro-Atlanta, one of the areas with the highest number of Vietnamese-Americans in the U.S. Survey data of 96 Vietnamese-American nonsmoking adults attending health fairs/programs hosted by community-based organizations (2017-2018) were analyzed. Acculturation-related predictors included Vancouver Acculturation Index, language fluency, years in the U.S., and area-level proportion of Asian residents. The sample was an average 37.49 years old and 65.3% female; the average number of years in the U.S. was 18.17 years. Past 30-day SHS exposure was reported by 21.9%. In multiple logistic regressions, the only variable associated with SHS exposure was the number of years living in the U.S. [OR = 0.91, CI = (0.85-0.99), p = 0.02]. Newly-immigrated Vietnamese-Americans have increased SHS exposure risk. Education about smoke-free policies and harmful effects of SHS may benefit this population.

Using graphic text-messaging to promote smoking cessation among first-generation Chinese and Korean male immigrants

First-generation Chinese and Korean male immigrants in the United States are at high risk for tobacco use. This study pilot-tested a graphic, native-language text-messaging intervention to promote smoking cessation among these groups. First-generation Chinese and Korean male immigrant smokers (N = 71) were recruited from the Washington DC area. Participants were randomly assigned to one of four conditions based on a between-subjects 2 (graphic plus text or text-only messages) � 2 (quitline information or quitting tips) design. The text-messaging intervention included 30 text messages in total and lasted one month. Participants completed an expired air carbon monoxide (CO) assessment and self-reported measures at both baseline and follow-up. Results show that, from baseline to follow-up, participants' expired air CO levels decreased significantly (P = 0.001). Attitude toward quitting also became more positive (P = 0.028). Compared with text-only messages, graphic text messages produced greater positive changes in quitting attitudes (P = 0.039) and elicited greater fear response (P = 0.005). Compared with quitting tip messages, quitline information resulted in greater regret (P = 0.016) and fear (P = 0.051). These findings suggest that graphic text-messaging can be an effective method to promote smoking cessation among first-generation Chinese and Korean male immigrants.

Contextual Factors Related to Conventional and Traditional Tobacco Use Among California Asian Indian Immigrants

California's tobacco control program contracted for tobacco use surveillance of Asian Indian Americans to address the paucity of information about tobacco use in this community, given their growing proportion of California's population. This study examined correlates of conventional (CTU) and Asian Indian traditional tobacco use (TTU) in a population-based sample of predominantly immigrant Asian Indian adults residing in California (N = 3228). The analytic sample (n = 2140) was limited to self-identified immigrants from India. Descriptive statistics, bivariate analyses, and multivariate logistic regressions were conducted to examine correlates of tobacco use among Asian Indian immigrants related to their acculturation and religious affiliation. While 65% of the sample had ever used traditional tobacco products (paan masala, gutka, bidis), only 25% had ever used conventional tobacco (cigarettes, cigar, pipe, chewing tobacco, snuff). Less than 5% reported tobacco use in the past 30 days. Rates of ever TTU and CTU were higher among men than women. Ethnic enclave residence was not associated with tobacco use. Impaired mental health was associated with CTU, and number of years spent in the U.S. was positively associated with both CTU and TTU. Individuals affiliated with Sikhism were less likely to use tobacco than individuals affiliated with Hinduism. Few population-based studies in the U.S. address both CTU and TTU use among Asian Indian immigrants. Tobacco use in Asian Indian immigrants may be seriously underestimated if surveillance is limited to conventional tobacco products. Interventions to reduce tobacco use should address mental health issues and consider religious affiliation.

Nicotine and addiction beliefs and perceptions among the US-born and foreign-born populations

Little is known about nicotine and addiction beliefs held by those who are foreign-born in the US and how these beliefs are associated with acculturation and race/ethnicity. This study attempts to address these research gaps. Data were analyzed from two cycles of the Health Information National Trends Survey, HINTS-FDA 2015 (n = 3738) and HINTS-FDA 2017 (n = 1736). HINTS-FDA is a tobacco-focused, cross-sectional, nationally representative survey of US non-institutionalized civilian adults aged 18 years or older. We first assessed associations between foreign-born status and beliefs about nicotine and addiction using weighted chi-square analyses. Then, using only the foreign-born sample, we examined the associations of nicotine and addiction beliefs with race/ethnicity and acculturation (i.e., English proficiency and U.S. tenure) using weighted multiple linear regression. Results showed that, compared to US-born respondents, foreign-born respondents were more likely to be concerned with being addicted to nicotine and to believe that low nicotine cigarettes would have much lower lung cancer risk than a typical cigarette. Among the foreign-born, NH-Black and Hispanic respondents were more likely to see low nicotine cigarettes as harmful and addictive compared to NH-White respondents. The relationship between acculturation and nicotine beliefs was complex with lower acculturation associated with elevated misperceived risk of nicotine and also ratings of addictiveness. Further research among key subpopulations may inform communication, education and dissemination strategies, especially among vulnerable populations.

Rapid Assessment for Establishing Evidence of an Underground Cigarette Market in Oakland Chinatown: A Dual Approach

We conducted a preliminary study to rapidly assess (1) whether an underground cigarette market exists in the area known as Oakland Chinatown in Oakland, California; and if so, (2) who consumes untaxed cigarettes in this ethnic enclave to provide a basis for further investigation.

Description of tobacco use and cessation among Bhutanese refugees participating in a tobacco cessation program

OBJECTIVES

To compare the tobacco use, exposure, and cessation differences between Bhutanese refugee and non-Hispanic Caucasian tobacco users in a US federally qualified health center tobacco cessation program.

DESIGN

A retrospective cohort study reviewing data from 374 patients counseled on tobacco cessation was performed. Demographic information, tobacco use history, exposure to tobacco, and type of tobacco used characterized baseline assessments. The patient record was followed forward in time to evaluate tobacco cessation outcomes as the dependent variable. Data were analyzed using odds ratios and the Mann-Whitney U-test.

RESULTS

Data analysis included 318 patients (211 non-Hispanic Caucasian patients and 107 Bhutanese refugee patients). Bhutanese refugees demonstrated a higher likelihood of smokeless tobacco product use than the non-Hispanic Caucasian population (67.3% vs 1%, OR = 214.971, 95% CI 50.429, 916.383), and a greater odds of having household tobacco users (OR = 2.533, 95% CI 1.532, 4.186). Likewise, the non-Hispanic Caucasian population exhibited larger odds of smoking cigarettes vs the Bhutanese population (97.2% vs 26.2%, OR = 96.399, 95% CI 38.449, 241.687), had a higher odds of passive smoke exposure (OR = 12.765, 95% CI 5.36, 30.393), and higher likelihood of a past quit attempt (OR = 9.037, 95% CI 5.180, 15.765). Significant gender differences with regard to type of tobacco used were noted among Bhutanese refugees. Bhutanese refugees demonstrated significantly higher likelihood of tobacco cessation, compared with the non-Hispanic Caucasian population, at all length cutpoints, while showing no difference in number of follow-up visits or median time followed.

CONCLUSION

These culture-specific findings, showing unique tobacco use characteristics and increased cessation among the Bhutanese refugee population, provide novel information helpful to professionals identifying and treating these individuals for tobacco cessation. More research is needed to confirm our results and findings.

Moving toward a true depiction of tobacco behavior among Asian Indians in California: Prevalence and factors associated with cultural smokeless tobacco product use

BACKGROUND

Asian Indians (AIs) in the United States exhibit disproportionate burdens of oral cancer and cardiovascular disease, which are potentially linked to smokeless tobacco. However, little is known about the use of cultural smokeless tobacco (CST) products in this population.

METHODS

California Asian Indian Tobacco Use Survey data from 2004 (n = 1618) were used to investigate CST prevalence among California's AIs. CST products included paan, paan masala, and gutka. A multivariable logistic regression was conducted to examine factors (socioeconomic status, acculturation measures, and religious affiliation) associated with current CST use versus never use.

RESULTS

The current CST prevalence was 13.0% (14.0% for men and 11.8% for women). In contrast, the prevalence of current cigarette use was 5.5% (8.7% for men and 1.9% for women), and the prevalence was lower for cultural smoked tobacco (0.1% for bidis and 0.5% for hookahs). Factors associated with CST use included the following: being male, being 50 years old or older, being an immigrant, speaking an AI language at home, having a higher level of education (adjusted odds ratio [AOR] for high school/some college, 2.6; 95% confidence interval [CI], 1.1-6.5; AOR for college degree or higher, 4.0; 95% CI, 1.7-9.5), having a higher income (AOR for $75,000-$100,000, 2.5; 95% CI, 1.3-4.7; AOR for ≥$100,000, 2.6; 95% CI, 1.4-5.0), identifying as non-Sikh (AOR for Hinduism, 10.0; 95% CI, 6.0-16.5; AOR for other faiths, 10.2; 95% CI, 5.9-17.7), and disagreeing that spiritual beliefs are the foundation of life (AOR, 2.1; 95% CI, 1.2-3.5).

CONCLUSIONS

The current CST prevalence is relatively high among California's AIs in comparison with the prevalence of smoking, with narrower differences between sexes. The association with a higher socioeconomic status is contrary to typical cigarette smoking patterns. Acculturation and religious affiliation are important factors associated with current use. Health care providers and policymakers should consider such determinants for targeted interventions. Cancer 2018;124:1607-13. © 2018 American Cancer Society.

Acculturation, Depression, and Smoking Cessation: a trajectory pattern recognition approach

BACKGROUND

Korean Americans are known for a high smoking prevalence within the Asian American population. This study examined the effects of acculturation and depression on Korean Americans' smoking cessation and abstinence.

METHODS

This is a secondary data analysis of a smoking cessation study that implemented eight weekly individualized counseling sessions of a culturally adapted cessation intervention for the treatment arm and a standard cognitive behavioral therapy for the comparison arm. Both arms also received nicotine patches for 8 weeks. A newly developed non-parametric trajectory pattern recognition model (MI-Fuzzy) was used to identify cognitive and behavioral response patterns to a smoking cessation intervention among 97 Korean American smokers (81 men and 16 women).

RESULTS

Three distinctive response patterns were revealed: (a) Culturally Adapted (CA), since all identified members received the culturally adapted intervention; (b) More Bicultural (MB), for having higher scores of bicultural acculturation; and (c) Less Bicultural (LB), for having lower scores of bicultural acculturation. The CA smokers were those from the treatment arm, while MB and LB groups were from the comparison arm. The LB group differed in depression from the CA and MB groups and no difference was found between the CA and MB groups. Although depression did not directly affect 12-month prolonged abstinence, the LB group was most depressed and achieved the lowest rate of abstinence (LB: 1.03%; MB: 5.15%; CA: 21.65%).

CONCLUSION

A culturally adaptive intervention should target Korean American smokers with a high level of depression and a low level of biculturalism to assist in their smoking cessation.

TRIAL REGISTRATION

NCT01091363. Registered 21 March 2010.

Review: Prevalence and co-occurrence of addictions in US ethnic/racial groups: Implications for genetic research

BACKGROUND AND OBJECTIVES

We conducted a review of the prevalence and co-occurrence of 12 types of addictions in US ethnic/racial groups and discuss the implications of the results for genetic research on addictions.

METHODS

We utilized MEDLINE and PsycINFO databases to review the literature on alcohol, tobacco, marijuana, illicit drugs, gambling, eating/food, internet, sex, love, exercise, work, and shopping. We present results for each addiction based on total US prevalence, prevalence within ethnic groups, and co-occurrence of addictions among ethnic groups when available.

RESULTS

This review indicates very little research has examined the interrelationships of addictive behaviors among US ethnic groups. The studies that exist have focused nearly exclusively on comorbidity of substances and gambling behaviors. Overall findings suggest differences among US ethnic groups in prevalence of addictions and in prevalence of addiction among those who use substances or engage in gambling. Almost no ethnic group comparisons of other addictive behaviors including eating/food, internet, love, sex, exercise, work, and shopping were identified in the literature.

CONCLUSIONS

Despite large-scale research efforts to examine alcohol and substance use disorders in the United States, few studies have been published that examine these addictive behaviors among ethnic groups, and even fewer examine co-occurrence and comorbidity with other addictions.

SCIENTIFIC SIGNIFICANCE

Even with the limited studies, these findings have implications for genetic research on addictive behaviors. We include a discussion of these implications, including issues of population stratification, disaggregation, admixture, and the interplay between genetic and environmental factors in understanding the etiology and treatment of addictions. (Am J Addict 2017;26:424-436).

A randomized controlled trial of a videoconferencing smoking cessation intervention for Korean American women: preliminary findings

Introduction

Korean women are reluctant to pursue in-person smoking cessation treatment due to stigma attached to women smokers and prefer treatment such as telephone and online smoking cessation programs that they can access secretively at home. However, there is some evidence that face-to-face interaction is the most helpful intervention component for them to quit smoking.

Methods

This study is a pilot clinical trial that examined the acceptability and feasibility of a videoconferencing smoking cessation intervention for Korean American women and compared its preliminary efficacy with a telephone-based intervention. Women of Korean ethnicity were recruited nationwide in the United States and randomly assigned at a ratio of 1:1 to either a video arm or a telephone arm. Both arms received eight 30-minute weekly individualized counseling sessions of a deep cultural smoking cessation intervention and nicotine patches for 8 weeks. Participants were followed over 3 months from the quit day.

Results

The videoconferencing intervention was acceptable and feasible for Korean women aged <50 years, whereas it was not for older women. Self-reported abstinence was high at 67% and 48% for the video and telephone arm at 1 month post-quit, respectively. The rates declined to 33% for the video arm and 28% for the telephone arm at 3 months post-quit when salivary cotinine test was performed.

Conclusion

Findings support that both videoconferencing and telephone counseling can be effective, and personal preference is likely an important factor in treatment matching. The deep cultural smoking cessation intervention may account for the outcomes of telephone counseling being better than prior studies in the literature for Korean women.

Asian Indians in America: The influence of values and culture on mental health

Asian Indians represent a significant portion of the largest growing race of Asians in the past decade in the United States. This selective review examines major cultural themes related to first- and second-generation Asian Indians living in the United States as they impact psychological and psychiatric dysfunction in this population. Specifically, we review the impact of Asian Indian culture on mental health, discuss the impact of acculturation and ethnic identity development on the mental health of Indian-Americans, and focus on typical mental health problems of Asian Indian adolescents, women and elderly in America. Finally, we provide a brief overview of empirically-supported treatment approaches and cultural considerations for additional treatments relevant to this population. This review is intended to provide an important foundation for more systematic empirically-driven investigation into better understanding how Asian Indian cultural themes impact mental health for Indian-Americans, and how to develop effective treatments for these issues in this cultural group.

Suffering in Silence: Impact of Tobacco Use on Communication Dynamics Within Vietnamese and Chinese Immigrant Families

The goal of this project was to explore family communication dynamics and their implications for smoking cessation. We conducted 39 in-depth dyadic and individual qualitative interviews with 13 immigrant smoker-family member pairs of Vietnamese ( n = 9 dyads, 18 individuals) and Chinese ( n = 4 dyads, 8 individuals) descent, including seven current and six former smokers and 13 family members. All 13 dyadic and 26 individual interviews were analyzed using a collaborative crystallization process as well as grounded theory methods. We identified three interrelated pathways by which tobacco use in immigrant Vietnamese and Chinese families impacts family processes and communication dynamics. Using a two-dimensional model, we illustrate how the shared consequences of these pathways can contribute to a dynamic of avoidance and noncommunication, resulting in individual family members "suffering in silence" and ultimately smoking being reinforced. We discuss the implications of these findings for development of smoking cessation interventions.

Effect of Length of Stay on Smoking among Turkish and Eastern European Immigrants in Germany--Interpretation in the Light of the Smoking Epidemic Model and the Acculturation Theory

Background: We analyzed changes in smoking by length of stay among immigrants in Germany and related them to the “smoking epidemic” model and the acculturation theory. Methods: We used data from a longitudinal survey (German Socio-economic Panel). Immigrants were identified by country of birth (Turkey: respondents n = 828, observations n = 3871; Eastern Europe: respondents n = 2009, observations n = 7202; non-immigrants: respondents n = 34,011, observations n = 140,701). Smoking status data was available for nine years between 1998 and 2012. Length of stay (LOS, in years) was used as proxy for acculturation. We calculated smoking prevalences, prevalence ratios and a random intercept multilevel logistic regression model. Results: With each year spent in Germany, smoking prevalence increases among Turkish women (OR = 1.14 (95%CI = 1.06–1.21)) and slightly decreases among men. Recently immigrated Turkish women smoke less than non-immigrant women (0–5 years: SPR = 0.25 (95%CI = 0.10–0.57)); prevalences converge with increasing LOS (31+ years: SPR = 1.25 (95%CI = 1.06–1.48)). Among Eastern European immigrants no significant changes were apparent. Conclusions: Immigrants from Turkey “import” their smoking prevalence from a country which is in the earlier stages of the “smoking epidemic”. With increasing LOS (thus, advancing acculturation), they “move” to the later stages. Anti-smoking interventions should consider different smoking attitudes in Turkey/Germany and need to discourage women from initiating smoking. Future research should also identify reasons for the possible differences between immigrant groups.

Gutka and Tambaku Paan use among South Asian immigrants: a focus group study

Smokeless tobacco use is prevalent among South Asian immigrants, particularly in the forms of gutka and tambaku paan. In this paper, we examined (a) gutka and tambaku paan initiation and use patterns among South Asian immigrants, and (b) perceptions related to quitting and tobacco control. Six focus groups were conducted with 39 South Asian adult gutka/tambaku paan users, in three different South Asian languages (Gujarati, Bengali, and Urdu). Participants reported easy availability of gutka and tambaku paan in neighborhood stores, and noted several factors that promoted initiation (including social networks, perceived benefits, and curiosity). Due to awareness of low social acceptance of gutka and tambaku paan in the US, some participants discussed changing patterns of use following immigration. Finally, participants proposed roles of various agencies (e.g., doctors'/dentists' role, government-led initiatives) for tobacco control in South Asian immigrant communities. This research provides implications for improving tobacco control efforts in the United States, particularly for South Asian immigrants.

A Culturally Adapted Smoking Cessation Intervention for Korean Americans: A Mediating Effect of Perceived Family Norm Toward Quitting

Korean men and women have the highest current smoking rates across all Asian ethnic subgroups in the United States. This is a 2-arm randomized controlled study of a culturally adapted smoking cessation intervention. The experimental condition received eight weekly 40-min individualized counseling sessions that incorporated Korean-specific cultural elements, whereas the control condition received eight weekly 10-min individualized counseling sessions that were not culturally adapted. All participants also received nicotine patches for 8 weeks. One-hundred nine Korean immigrants (91 men and 18 women) participated in the study. The rate of biochemically verified 12-month prolonged abstinence was significantly higher for the experimental condition than the control condition (38.2 vs. 11.1 %, χ (2) = 10.7, p < 0.01). Perceived family norm significantly mediated the effect of cessation intervention on abstinence. Smoking cessation intervention for Korean Americans should be culturally adapted and involve family members to produce a long-term treatment effect.

Acculturation and smoking in North Americans of Chinese ancestry: A systematic review

OBJECTIVES

Many North American immigrants come from China. Given the critical impact of tobacco use on health, it is important to understand rates and correlates of smoking in this population. This systematic review addressed the question: based on current research, what is the association between acculturation and smoking behaviours in Chinese immigrants to North America?

METHODS

The search was conducted in PubMed, Medline, Web of Science, and Academic Search Complete for papers published from 2005 to 2014. Data were extracted from Canadian and American studies for population characteristics, study design, measures of smoking and acculturation, and findings regarding smoking rates and associations between smoking and acculturation.

SYNTHESIS

The literature search identified 147 articles, and 14 met inclusion criteria. Three studies were based on Canadian samples and the remaining 11 were from the United States. Of the 14 papers, 3 reported findings for youth and 11 for adults. Among adults, daily smoking rates were consistently much higher in men than women; for men, rates varied from 9% to 30%. Language use and time in North America were the most common indicators of acculturation. Almost all studies found a relationship between acculturation and smoking, such that more acculturated men smoke less and more acculturated women smoke more.

CONCLUSION

The findings suggest that the association between acculturation and smoking is gender-specific. This correlation is found in youth and adults and in both Canada and the US. Increased acculturation has a protective effect on smoking for Chinese North American men, but a harmful effect for women. Tobacco control interventions need to develop targeted strategies appropriate to these different populations.

Factors associated with smoking in immigrants from non-western to western countries - what role does acculturation play? A systematic review

INTRODUCTION

We aimed to identify factors associated with smoking among immigrants. In particular, we investigated the relationship between acculturation and smoking, taking into consideration the stage of the 'smoking epidemic' in the countries of origin and host countries of the immigrants.

METHODS

We searched PubMed for peer-reviewed quantitative studies. Studies were included if they focused on smoking among adult immigrants (foreign-born) from non-western countries now residing in the USA, Canada, Ireland, Germany, the Netherlands, Norway, the UK, and Australia. Studies were excluded if, among others, a distinction between immigrants and their (native-born) offspring was not made.

RESULTS

We retrieved 27 studies published between 1998 and 2013. 21 of the 27 studies focused on acculturation (using bidimensional multi-item scales particularly designed for the immigrant group under study and/or proxy measures such as language proficiency or length of stay in host country) and 16 of those found clear differences between men and women: whereas more acculturated women were more likely to smoke than less acculturated women, the contrary was observed among men.

CONCLUSION

Immigrants' countries of origin and host countries have reached different stages of the 'smoking epidemic' where, in addition, smoking among women lags behind that in men. Immigrants might 'move' between the stages as (I) the (non-western) countries of origin tend to be in the early phase, (II) the (western) host countries more in the advanced phase of the epidemic and (III) the arrival in the host countries initiates the acculturation process. This could explain the 'imported' high (men)/low (women) prevalence among less acculturated immigrants. The low (men)/high (women) prevalence among more acculturated immigrants indicates an adaptation towards the social norms of the host countries with ongoing acculturation.

Disseminating tobacco control information to Asians and Pacific Islanders

The Asian Grocery Store-Based Cancer Education Program (the Program) is a proven strategy for promoting early breast cancer detection among Asian American women. The authors sought to test whether the same public health model can become an effective strategy for increasing the Asian community's awareness of the California Smokers' Helpline (the Helpline) and thereby, potentially decreasing this community's use of tobacco products. The new module, mainly staffed by four well-trained, volunteer undergraduates, explained the risks of first- and second-hand tobacco exposure and how to access the Helpline's services. A brochure, provided in English, Chinese, Korean, and Vietnamese (the Helpline's available Asian languages), was used to guide the bicultural, bilingual students' tobacco-related discussions with shoppers. The students' repeated presence at the nine partnering Asian grocery stores served as reminders of the Helpline's availability. In its first year of operation, the student trainers reached 1,052 men and 1,419 women with tobacco cessation messages. Equally important, the participating grocery stores' managers did not object to students telling their customers to quit using the tobacco products sold in their stores. The results suggest that the Program's tobacco cessation module is a viable, community-specific, public health strategy. It is also a strategy with the potential for applications to reduce other health threats.

The Relationship Between Duration of U.S. Residence, Educational Attainment, and Adult Health Among Asian Immigrants

There is substantial educational heterogeneity among Asian immigrants to the United States, suggesting that the association between duration of U.S. residence with their health outcomes and behaviors may vary considerably by educational attainment. Using data from the 2003 New Immigrant Survey (N=2,373), we find strong evidence that the detrimental associations between duration of U.S. residence and self-reported health, activity limitation status, chronic health conditions and current smoking are concentrated among Asian immigrants with less than a high school education; in contrast, the health outcomes and behaviors of Asian immigrants who have at least a high school degree exhibit very few differences by duration of U.S. residence. These distinct duration-health patterns by educational attainment are not explained by duration related differences in country of origin, class of admission, or English speaking skills. We also find a stronger duration relationship with current smoking than those with the health status measures among the least educated Asian men, indicating a potential behaviorally-based explanation for poorer health among Asian immigrant men with longer duration of residence.

Smoking during pregnancy among Turkish immigrants in Germany-are there associations with acculturation?

INTRODUCTION

We analyzed the association between different acculturation measures and smoking among pregnant immigrant women from Turkey and compared smoking rates between Turkish and German women.

METHODS

Perinatal data from a project on the influence of migration and acculturation on pregnancy and birth in Berlin was analyzed. An acculturation index (FRAKK) and two proxy measures (German language proficiency, length of stay in Germany) were used. We performed logistic regression models and calculated age-standardized prevalence ratios (SPR).

RESULTS

Smoking prevalence was 19.8% among pregnant Turkish women (n = 702) and 17.8% among German women (n = 2,999). The chance of being a smoker was significantly higher among Turkish women with a length of stay of ≥20 years compared to 0-4 years (OR = 3.63, 95% CI = 1.64-8.05); with good/very good language skills compared to none/minor skills; with high levels of acculturation compared to low levels (the latter only among 18-29-year-old women). Compared to German women, Turkish women with a short length of stay, low acculturation scores and none/minor language skills had lower smoking rates. This finding inverts with long length of stay, high acculturation scores and good/very good language skills (≥20 years: SPR = 2.14, 95% CI = 1.56-2.94).

CONCLUSIONS

Smoking among pregnant Turkish women increases with increasing acculturation. Additionally, immigrant women with a low acculturation level are less often smokers and women with a high level are more often smokers than German women. Prevention measures have to prevent women with a low acculturation from starting to smoke and to induce those with a high acculturation to quit. As smoking and acculturation are group phenomena, it is necessary to involve immigrant communities.

Does smoking initiation in adolescence increase risk for depression across the lifespan? Evidence from the South korean national health and nutrition examination survey

The association between smoking and depression has been well stated in the literature. However, the mechanisms underlying this phenomenon are still unclear. Recent research using an animal model suggests that even low-level nicotine exposure during adolescence has long-lasting effects on the development of depression. This study aims to examine the association between smoking initiation and depression analyzing secondary data. A sample that is representative of the South Korean adult population was selected from the Fourth Korea National Health and Nutrition Examination Survey collected from 2007 to 2009 (N = 18,406). Regardless of life stage of smoking initiation, smokers had greater risk for depression in adulthood than nonsmokers after adjusting for demographics and other depression-related covariates. The results indicate that, with regard to risk for depression, it is important to prevent smoking initiation at any life stage. Successful implementation of smoking prevention strategies should lead to enhanced mental (i.e., reduced risk for depression) as well as physical health of adults in the long run.

How immigrants adapt their smoking behaviour: comparative analysis among Turkish immigrants in Germany and the Netherlands

BACKGROUND

Smoking behaviour among immigrants is assumed to converge to that of the host country's majority population with increasing duration of stay. We compared smoking prevalence among Turkish immigrants residing in two different countries (Germany (DE)/the Netherlands (NL)) between and within countries by time spent in Turkey and DE/NL.

METHODS

The German 2009 micro-census and the Dutch POLS database (national survey, 1997-2004) were analysed. An interaction variable with dichotomised length of stay (LOS) in Turkey (age: 0-17; 18+) and categorised LOS in the host country (immigration year: 1979 and earlier, 1980-1999, 2000-2009; the latter only for Germany) was generated. Age standardised smoking prevalences and sex-specific logistic regression models were calculated.

RESULTS

6,517 Turkish participants were identified in Germany, 2,106 in the Netherlands. Age-standardised smoking prevalences were higher among Turkish immigrants in the Netherlands compared to those in Germany: 62.3% vs. 53.1% (men/lower education); 30.6% vs. 23.0% (women/lower education). A similar trend was observed for the majority population of both countries. The chance of being a smoker was lower among Turkish men with short LOS in Turkey and middle LOS in Germany/the Netherlands compared to those with short LOS in Turkey and long LOS in Germany/the Netherlands (NL: OR = 0.57[95% CI = 0.36-0.89]; DE: OR = 0.73[95% CI = 0.56-0.95]). Contrary to that, the chance of being a smoker was higher among Turkish men with long LOS in Turkey and middle LOS in Germany/the Netherlands compared to those with long LOS in Turkey and long LOS in Germany/the Netherlands (NL: OR = 1.35[95% CI = 0.79-2.33]; DE: OR = 1.44[95% CI = 1.03-2.02]). The effects for Turkish women were similar, but smaller and often non-significant.

CONCLUSION

Turkish immigrants adapt their smoking behaviour towards that of the Dutch/German majority population with increasing duration of stay. This was particularly obvious among those who left Turkey before the age of 18 years - a group that needs tailored interventions to prevent further increases in smoking. Those who left Turkey as adults and spent a short time in the host countries show 'imported' smoking patterns. A limitation of this study is the use of cross-sectional data: a cohort effect cannot be ruled out. Our findings have to be confirmed with longitudinal data.

Culture, acculturation and smoking use in Hmong, Khmer, Laotians, and Vietnamese communities in Minnesota

BACKGROUND

Southeast Asian communities in the United States have suffered from high rates of tobacco use and high rates of chronic diseases associated with firsthand and secondhand smoking. Research is needed on how best to reduce and prevent tobacco use and exposure to secondhand smoke in these communities. The objective of this study was to examine how tobacco use patterns in Minnesota's Southeast Asian communities have been shaped by culture, immigration, and adjustment to life in America in order to inform future tobacco control strategies.

METHODS

The study consisted of semi-structured interviews with 60 formal and informal leaders from Minnesota's Hmong, Khmer (Cambodian), Lao, and Vietnamese communities and incorporated principles of community-based participatory research.

RESULTS

Among Khmer, Lao and Vietnamese, tobacco in the homeland was a valued part of material culture and was used to signify social status, convey respect, and support social rituals among adult men (the only group for whom smoking was acceptable). Among the Hmong, regular consumption of tobacco was unacceptable and rarely seen until the civil war in Laos when a number of Hmong soldiers became smokers. In Minnesota, social norms have begun to shift, with smoking becoming less acceptable. Although older male smokers felt social pressure to quit, smoking functioned to reduce the stress of social isolation, economic hardship, prior trauma, and the loss of power and status. Youth and younger women no longer felt as constrained by culturally-rooted social prohibitions to smoke.

CONCLUSIONS

Leaders from Minnesota's Southeast Asian communities perceived key changes in tobacco-related attitudes, beliefs, and behaviors which were embedded in the context of shifting power, status, and gender roles within their communities. This has practical implications for developing policy and interventions. Older Southeast Asians are likely to benefit from culturally-tailored programs (e.g., that value politeness and the importance of acting in ways that benefit the family, community, and clan) and programs that work with existing social structures, as well as initiatives that address smokers' psychological distress and social isolation. Leaders remained uncertain about how to address smoking uptake among youth, pointing to a need for additional research.

Place matters in perceived tobacco exposure among Korean American young adults: mixed methods approach

A sequential mixed methods study was conducted to identify factors influencing perceived norms about smoking and to examine the association of acculturative contexts and normative beliefs among Korean American young adults (KAYA) who face increased risk of smoking. Content analysis of data from 67 participants in 10 focus groups in 2010 led to the development of an online survey in 2012 (N = 475). KAYA overestimated smoking prevalence, reporting Korean-owned businesses (KOB) as primary places of exposure. Our findings revealed that visits to KOB predicted perceived norms about smoking. Modifying perceptions about social norms and involuntary tobacco exposure may be critical in reducing smoking among KAYA. The study's limitations are noted.

Asian American, Native Hawaiian and Pacific Islander tobacco use patterns

OBJECTIVES

To provide a national depiction of Asian American (AA) and Native Hawaiian/Pacific Islander (NHPI) tobacco use and highlight considerations for targeted interventions.

METHODS

We analyzed data from the 2009-2010 National Adult Tobacco Survey for subgroup differences in prevalence and consumption of various tobacco products.

RESULTS

Use varies considerably by ethnic subgroups for cigarette smoking (including menthol) and other forms of tobacco. Despite being lighter, less frequent, and seemingly less dependent smokers, AANHPIs had similar quit ratios as non-AANHPIs.

CONCLUSIONS

AA and NHPI disparities in tobacco use may be due to underutilization of cessation resources, including those for non-cigarette tobacco products, and lack of availability of culturally-appropriate resources. Community-based and regulatory approaches should be employed to reduce use of all tobacco products, especially among high prevalence subgroups.

Knowledge of Occupational Chemical Exposure and Smoking Behavior in Korean Immigrant Drycleaners

To examine the association between knowledge of chemical exposure at work and cigarette smoking among Korean immigrant drycleaners. A cross-sectional survey was conducted with a total of 151 Korean immigrant drycleaners (mean age = 49 years, 64 % male) from 96 drycleaning shops in a Midwestern state. The data were collected on demographic and work-related characteristics, knowledge of occupational chemical exposure, health concerns associated with chemical exposure, and smoking status. Approximately 25 % of participants were current smokers. The multivariate regression showed that greater knowledge of occupational chemical exposures was significantly associated with a lower likelihood of current smoking [odds ratio (OR) .63; 95 % confidence interval (CI) .41-.95]. Furthermore, male gender (OR 6.32; 95 % CI 1.66-24.00), shorter-term residence in the US (OR .93; 95 % CI .88-.98), and having multiple duties (OR 2.76; 95 % CI 1.01-7.51) were important covariates associated with current smoking among Korean immigrant drycleaners. Knowledge on occupational chemical exposure was significantly associated with smoking among Korean immigrant drycleaners. Smoking cessation programs for this population should consider integrated approaches that incorporate work environment factors into individual and sociocultural components.

Prospective Evaluation of Factors Predicting Nicotine Withdrawal Symptoms Among Korean Americans

INTRODUCTION

This study examined factors predicting nicotine withdrawal symptoms following quitting among Korean American smokers who were receiving counseling and nicotine replacement therapy.

METHODS

The sample comprised 90 Korean American smokers selected from a two-arm randomised controlled trial of a smoking cessation intervention (culturally adapted versus treatment as usual). Nicotine withdrawal symptoms were assessed weekly for the first four weeks from the target quit day, using the Minnesota Nicotine Withdrawal Scale (MNWS). Only those who participated in two or more weekly assessments of the symptoms were included.

RESULTS

Among the nine withdrawal symptoms listed in the MNWS, craving and disturbed sleep decreased over time whereas the remaining symptoms had no significant effect of time. Women or individuals who perceived greater risks of quitting smoking reported more withdrawal symptoms after controlling for abstinence status. Although withdrawal symptoms did not change, on average, with time, the rates of change varied randomly across individuals. Women reported more withdrawal symptoms in the first week after quitting and showed a higher rate of decline of the symptoms over time than men.

CONCLUSIONS

Korean American smokers who are women or who perceive greater risks of quitting smoking may require more intensive treatment to effectively deal with post-quit withdrawal symptoms.

Cigarettes, culture, and Korean American emerging adults: an exploratory qualitative study

Korean American emerging adults (KAEA) constitute an understudied, at-risk group for smoking and related health consequences. The cultural meanings of smoking and cessation among KAEA were explored. Sixty-seven KAEA participated in 10 focus groups. Themes from the sessions were identified and domain analysis was conducted. Regarding reasons for smoking, we identified (a) association between the culture of origin and gender identification, (b) access/availability of cigarettes in homes/community, and (c) competing social environments where KAEA adjust their health behaviors. Regarding contexts for cessation, we identified (a) a sense of invincibility/denial, (b) lack of role models or pressure to quit, and (c) lack of significant life events. Using cessation aids represented lacking personal discipline/willpower. The results show that smoking among KAEA is highly contextualized in the culture of origin, despite U.S. tobacco control policies. Implications for culturally sensitive prevention/cessation programs for KAEA include modifying culturally based norms and social spaces regarding cigarettes and cessation.

Korean American Women's Experiences with Smoking and Factors Associated with Their Quit Intentions

This study explored Korean American women's experiences with smoking and tested the theory of planned behavior to identify factors associated with their intentions to quit smoking. It employed a mixed-methods research design, using qualitative and quantitative data. Participants were recruited via a combination of random (N = 49) and convenience (N = 45) sampling techniques. Women in this study initiated smoking at age of 23 on average, and nearly half smoked at indoor houses. They initiated smoking out of curiosity about the effect and belief that smoking would relieve their stress. Reasons for continued smoking were (a) to avoid nicotine withdrawal symptoms, (b) to cope with life stressors, including acculturative stress, and (c) to fulfill one's destiny as a lifetime smoker. Many attempted to quit due to health issues and pregnancy. Fear of disclosure and limited English proficiency were found to be major barriers to seeking help for quitting. Past-year quit attempt(s), attitudes toward quitting, and perceived family norm favoring quitting explained 25% of the variance in intentions to quit smoking (F [3,90] = 11.58, P < 0.001). Findings suggest that gender- and culture-specific intervention strategies are needed to assist Korean American women in smoking cessation.

Culturally Specific Tobacco Use and South Asians in the United States

Over the past two decades, the United States has attracted large South Asian populations, who have imported tobacco products previously unique to the native subcontinent. South Asian cigarette use prevalence is consistently lower than other U.S. Asian subgroups; however, most surveys fail to capture smokeless products accurately. In part because of the pervasive use of popular smokeless cultural products resulting in greater population attributable risk of oral malignancies, many countries outside the United States have developed surveillance systems to capture these products and implemented effective population-level or community-based intervention strategies. This minority population in the United States continues to be “at risk” of suffering from a disproportionate burden of diseases, which are plausibly linked to the use of these products. The primary focus of this article is to provide an exhaustive literature review of tobacco use patterns and existing tobacco control strategies among South Asians in the United States. Framed within the social ecological model, the article suggests that there needs to be more detailed assessment of cultural tobacco products, a concurrent increase in cultural competencies of health care providers and provision of cessation resources outside the clinical setting. At the policy level, future efforts should adequately regulate these products and oversight must include such products in efforts to reduce rates of use. Concurrently, community-based efforts are needed to change social norms related to perceived health benefit and lack of stigma. This will help ensure that appropriately framed messages around use rates and burden of disease are addressed through culturally valued institutions and leaders.

Smoking cessation counseling for Asian immigrants with serious mental illness: using RE-AIM to understand challenges and lessons learned in primary care-behavioral health integration

Engagement in modifiable risk behaviors, such as tobacco use, substantially contributes to early mortality rates in individuals with serious mental illness (SMI). There is an alarmingly high prevalence of tobacco use among subgroups of Asian Americans, such as immigrants and individuals with SMI, yet there are no empirically supported effective smoking cessation interventions that have been tailored to meet the unique cultural, cognitive, and psychological needs of Asian immigrants with SMI. In this article, we share the experiences of clinicians in the delivery of smoking cessation counseling to Asian American immigrants with SMI, in the context of an Asian-focused integrated primary care and behavioral health setting. Through a qualitative analysis of clinician perspectives organized with the RE-AIM framework, we outline challenges, lessons learned, and promising directions for delivering smoking cessation counseling to Asian American immigrant clients with SMI.

Smoking among Asian Americans: acculturation and gender in the context of tobacco control policies in New York City

New York City (NYC) has experienced significant decline in smoking prevalence since its antismoking campaign; however, the rates among NYC's Asian communities have persisted since 2002. Using combined data from the REACH US Risk Factor Survey (2009-2011), this article examined ethnic- and gender-specific smoking behaviors and the effects of acculturation and location of residence on cigarette smoking behavior among Chinese, Korean, Asian Indians, and other Asian Americans. Results indicated that current smoking prevalence was higher for men than women among all four groups. Korean men and women had the highest current smoking rates whereas Indians had the lowest among the four subgroups. Asian American women reporting speaking only English at home had higher current smoking prevalence, but this was not observed for men. Living in Sunset Park, an emerging Asian ethnic enclave, was associated with higher odds of smoking than living in other locations in NYC. In conclusion, smoking prevalence varied across gender and ethnic subgroups among Asian Americans in NYC. A "one-size-fits-all" type of intervention strategy for "pan-Asians" could not be effective. Community-based culturally appropriate and gender-specific interventions for smoking cessation might be an option for Asian Americans residing in linguistically isolated ethnic enclaves.

Ethnic differences in smoking rate, nicotine dependence, and cessation-related variables among adult smokers in Hawaii

This study tests hypotheses concerning ethnic disparities in daily cigarette smoking rates, nicotine dependence, cessation motivation, and knowledge and past use of cessation methods (e.g., counseling) and products (e.g., nicotine patch) in a multiethnic sample of smokers in Hawaii. Previous research has revealed significant differences in smoking prevalence among Native Hawaiians, Filipinos, Japanese, and Caucasians in Hawaii. However, no study has examined differences in dependence and cessation-related knowledge and practices among smokers representing these ethnic groups. Participants were recruited through newspaper advertisement as part of a larger smoking cessation intervention study. Participants (N = 919; M age = 45.6, SD = 12.7; 48 % women) eligible to participate provided self-report data through mail and telephone. Participants included 271 self-identified Native Hawaiians, 63 Filipinos, 316 Caucasians, 145 "East Asians" (e.g., Japanese, Chinese), and 124 "other" (e.g., Hispanic, African-American). Pair-wise comparisons of means, controlling for age, gender, income, education, and marital status, indicated that Native Hawaiian smokers reported significantly higher daily smoking rates and higher levels of nicotine dependence compared to East Asians. Native Hawaiian smokers reported significantly lower motivation to quit smoking than Caucasians. Further, Filipino and Native Hawaiian smokers reported lesser knowledge of cessation methods and products, and less frequent use of these methods and products than Caucasians. The results suggest that Native Hawaiian and Filipino smokers could be underserved with regard to receiving cessation-related advice, and may lack adequate access to smoking cessation products and services. In addition, cessation interventions tailored for Native Hawaiian smokers could benefit from a motivational enhancement component.

Clinico-epidemiological profile of tobacco users attending a tobacco cessation clinic in a teaching hospital in Bangalore city

Background:

Tobacco-attributable mortality in India is estimated to be at least 10%. Tobacco cessation is more likely to avert millions of deaths before 2050 than prevention of tobacco use initiation.

Objective:

To describe the clinico-epidemiological profile of attendees of a tobacco cessation clinic in a teaching hospital in Bangalore city.

Materials and Methods:

A descriptive study of 189 attendees seen over 2 years in the Tobacco Cessation Clinic of a tertiary-care teaching hospital in Bangalore, with information on socio demographic characteristics, tobacco-use details, nicotine dependence, family/medical history, past quit attempts, baseline stage-of-change, and treatment initiated.

Results:

Only 5% were ‘walk-in’ patients; 98% of attendees were smokers; 97% were males. The mean (±SD) age of attendees was 48.0 (±14.0) years. Most participants were married (88%), and predominantly urban (69%). About 62% had completed at least 8 years of schooling. Two-thirds of smokers reported high levels of nicotine dependence (Fagerström score >5/10). About 43% of patients had attempted quitting earlier. Four-fifths (79%) of tobacco-users reported a family member using tobacco. Commonly documented comorbidities included: Chronic respiratory disease (44%), hypertension (23%), diabetes (12%), tuberculosis (9%), myocardial infarction (2%), stroke (1%), sexual dysfunction (1%) and cancer (0.5%). About 52% reported concomitant alcohol use. At baseline, patients’ motivational stage was: Precontemplation (14%), contemplation (48%), preparation/action (37%) and maintenance (1%). Treatment modalities started were: Counseling alone (41%), nicotine replacement therapy alone (NRT) (34%), medication alone (13%), and NRT+medication (12%).

Conclusions:

This is the first study of the baseline profile of patients attending a tobacco cessation clinic located within a chest medicine department in India. Important determinants of outcome have been captured for follow-up and prospective documentation of outcomes.

Tobacco dependence treatment for Korean Americans: preliminary findings

The study was conducted to examine the relative effectiveness of cognitive behavior therapy with a cultural tailoring intervention compared to brief medication management. The study used a two-arm randomized controlled trial in which participant assignment was stratified by gender. The intervention condition received eight weekly 40-min individualized counseling sessions of culturally tailored cognitive behavior therapy, while the control condition received eight weekly 10-min individualized counseling sessions of medication management. Both conditions received nicotine patches for 8 weeks. Data were collected at baseline and at four follow-up points (one and 4 weeks, and three and 6 months post-quit). Treatment outcomes were presented as an intention-to-treat analysis. Thirty Korean immigrants participated in the study. At 6-month follow-up, 57.1% of participants in the intervention and 18.8% of participants in the control had 7-day point prevalence abstinence (odds ratio = 5.8, 95% confidence interval = 1.12-26.04, P = 0.04). Participants' self-reported abstinence was biochemically verified with exhaled carbon monoxide and salivary cotinine levels. A combination of the culturally tailored cognitive behavior therapy and nicotine replacement therapy had a better treatment outcome compared to brief medication management. The promising result suggests a need to further test the intervention in larger samples and longer follow-up assessments before it can be adapted in clinical settings.

Smoking and Nicotine Dependence in Singapore: Findings from a Cross-Sectional Epidemiological Study

Introduction: Smoking is one of the leading preventable causes of death throughout the world and can lead to nicotine dependence, particularly when initiated at a young age. This paper describes the prevalence of smoking and nicotine dependence in the adult Singapore resident population, whilst also exploring rates among the major ethnic groups (Chinese, Malay and Indian), different education levels and those with chronic psychiatric and physical comorbidities. Material and Methods: The Singapore Mental Health Study (SMHS) is a cross-sectional epidemiological study that was conducted between December 2009 and December 2010. Information on smoking status was assessed using the Composite International Diagnostic Interview version 3.0 (CIDI 3.0) and the Fagerstrom Test for Nicotine Dependence measured nicotine dependence. Socio-demographic information was also collected. Results: In total, 6616 respondents participated in the SMHS giving a response rate of 75.9%. We found that 16% of the population were current smokers and 4.5% had nicotine dependence. Current smokers were more likely to be younger (18 to 34 years old), males, Malay and have lower education, whilst males had a 4.6 times higher risk of nicotine dependence to that of females. The prevalence of nicotine dependence was also higher in those with alcohol abuse and those experiencing chronic pain. Conclusion: The results from this study highlight the important differences in the prevalence of smoking and nicotine dependence among different age groups, gender and ethnicity in Singapore and are important for developing future health policies and targeted preventive strategies. Key words: Ethnicity, Gender, Population, Prevalence

Gender Differences in the Fagerström Test for Nicotine Dependence in Korean Americans

INTRODUCTION: This study was conducted to compare gender differences in the psychometric properties of the Fagerström Test for Nicotine Dependence (FTND). METHODS: The sample comprised 334 Korean immigrants (97 women and 237 men) who reported daily smoking for the past six months. Item-by-item responses and exploratory factor analyses (EFA) were compared by gender. Promax rotation was selected based on findings from previous studies suggesting correlated factors. RESULTS: Compared with men, women smoked fewer cigarettes per day, were more likely to smoke when ill in bed, and were less likely to smoke frequently in the morning. The entire sample and men within the sample had the same factor loading pattern, where three items (time to first cigarette, the cigarette most hate to give up, and smoke more frequently in the morning) were loaded on Factor 1 (morning smoking) and the remaining three items (difficult to refrain from smoking in public places, number of cigarettes smoked per day, and smoking even when ill in bed) on Factor 2 (daytime smoking). For women, however, neither the 1- nor 2-factor model fit the data well. CONCLUSIONS: For Korean American male smokers, the psychometric properties of the FTND were similar to those seen in other populations, but this was not the case with Korean American women. Clinicians may need to modify their interpretation of nicotine dependence severity if basing only on the FTND with Korean Women. The FTND assesses smoking patterns which has a cultural influence and other measures of nicotine dependence should be considered.

The most critical unresolved issues associated with race, ethnicity, culture, and substance use

This paper discusses the limitations of previous research on race, ethnicity, culture, and substance use. The study offers the following recommendations for future research in this area: (1) move beyond simple comparisons of mutually exclusive groups, (2) focus on the meaning of an ethnic label to the individual, (3) consider the complex interactions between an individual's cultural identity and the cultural context, (4) understand and acknowledge the researcher's inherent biases, and (5) translate research findings into practice and policy change.

Asian Smokefree Communities: Evaluation of a Community-Focused Smoking Cessation and Smokefree Environments Intervention In New Zealand

Language, culture and not knowing how to access services are barriers to the use of health services for Asian migrants. Asian Smokefree Communities (ASC) pilot-tested a novel Asian-specific service model to address these issues for Asian smokers. Korean- and Chinese-speaking coordinators delivered home-, workplace- or clinic-based interventions to support smokers with cessation and create smoke-free environments with families. A prior planned evaluation investigated the acceptability of the service, quit rates and exposure to second-hand smoke. The methods included analysis of ASC service records, a client satisfaction survey and key informant interviews. Clients were satisfied with factors associated with culture, such as being comfortable when talking to coordinators (88.9%) and family involvement in treatment (79.4%). Appointment attendance was high (97%). The self-reported quit rate for the 93 cessation clients was 72% at 1 month, 53.8 % at 3 months and 40.9 % at 6 months. All homes (100%) were smoke-free after the intervention, an increase of 18% from preintervention levels. The ASC model was acceptable to Asian clients. It helped them stop smoking and increased household protection from second-hand smoke. The model could make an effective contribution to smoke-free services for Asian populations in western countries.

Culture and smoking among Vietnamese Americans in central Massachusetts

The study was conducted (a) to assess use of any smoking cessation medications, (b) to identify factors associated with smoking, and (c) to assess knowledge of the health effects of smoking and attitudes toward smoking and seeking help for quitting among Vietnamese Americans. This is a descriptive study conducted with a nonrepresentative sample of 163 Vietnamese Americans. Current and former smokers constituted 24.4% and 25.6% of men and 1.2% and 3.5% of women, respectively. Of 20 current smokers, 17 (85%) reported use of cessation medications in their past quit attempts. Acculturation was the only significant correlate of ever smoking (vs. never smoking) in multivariate logistic regression analyses. Men who were less acculturated had more than 5 times the odds of being ever smokers (odds ratio = 5.33, 95% confidence interval = 1.37-20.78) compared with more acculturated men. Most participants had correct knowledge of the health effects of smoking regardless of age, education level, and smoking status. Attitudes toward smoking differed by age and education level but not by smoking status. Nurses working with Vietnamese Americans should be aware of the high rate of smoking among male immigrants and provide smoking cessation interventions.