11

Smoking among Smoking among Vietnamese American Vietnamese American men in relation to men in relation to traditional health traditional health beliefsbeliefs

Presenter: Nadine L. Chan, MPHPresenter: Nadine L. Chan, MPHEmail: nadine_chan@yahoo.comEmail: nadine_chan@yahoo.comUniversity of Washington & University of Washington & Fred Hutchinson Cancer Research CenterFred Hutchinson Cancer Research CenterNational Conference on Tobacco or Health National Conference on Tobacco or Health December 11, 2003December 11, 2003

22

AcknowledgementsAcknowledgements

Vietnamese Community Coalition and Vietnamese Community Coalition and InterviewersInterviewers

Vicky Taylor MD, MPHVicky Taylor MD, MPH Yutaka Yasui PhDYutaka Yasui PhD Carey Jackson MD MPHCarey Jackson MD MPH Beti Thompson PhDBeti Thompson PhD NCI Grant #CA823226-01NCI Grant #CA823226-01 Biobehavioral Cancer Prevention and Biobehavioral Cancer Prevention and

Control Training Program: NCI Grant Control Training Program: NCI Grant #R25 CA92408 #R25 CA92408

33

AgendaAgenda

Background on Background on – smoking among Southeast Asianssmoking among Southeast Asians– traditional health practices traditional health practices

Vietnamese Health Study in Vietnamese Health Study in Seattle, WASeattle, WA

MethodsMethods FindingsFindings ImplicationsImplications

44

Background: Tobacco Background: Tobacco UseUse Tobacco use is single most preventable Tobacco use is single most preventable

cause of death and illness in US cause of death and illness in US CDC, 1998CDC, 1998

– One in five deaths One in five deaths – 87% of lung cancer deaths87% of lung cancer deaths

Lung cancer is the leading cause of Lung cancer is the leading cause of cancer death among all Americanscancer death among all Americans

Lung cancer rates in Southeast Asians Lung cancer rates in Southeast Asians are 18% higher than general population are 18% higher than general population Chen and Hawks, 1995Chen and Hawks, 1995

55

Smoking PrevalenceSmoking Prevalence

PrevalencePrevalence– 34% to 43% among Southeast Asian men 34% to 43% among Southeast Asian men

vs.vs.– 27% in white men 27% in white men Centers for Disease Control Centers for Disease Control

and Prevention, 2000and Prevention, 2000

Tobacco use different by sexTobacco use different by sex– Much higher in API men than in womenMuch higher in API men than in women– More than 70% of newer male immigrants More than 70% of newer male immigrants

from Laos or Cambodia smoke from Laos or Cambodia smoke

66

Prevalence in King Prevalence in King County, WACounty, WA

% Current Smokers 1995-1996King County

12%17%

21%

38%

1%0%5%

10%15%20%25%30%35%40%

Hea

lthy

Peop

le20

10O

bjec

tives

Kin

gC

ount

y

Vie

tnam

ese

Vie

tnam

ese

men

Vie

tnam

ese

wom

en

%C

urr

en

t S

mo

kers

King County Ethnicity and Health Survey, 1998

77

Why?Why?

88

Challenges for Tobacco Challenges for Tobacco ControlControl More than 50% of tobacco companies More than 50% of tobacco companies

exports are sent to Asian countriesexports are sent to Asian countries Higher density of billboards and store Higher density of billboards and store

displays in Asian neighborhoods (e.g. displays in Asian neighborhoods (e.g. San Diego)San Diego) Elder et al, 1993Elder et al, 1993

– 6.4/Asian store6.4/Asian store– 4.6/Latino store4.6/Latino store– 3.7/African American store3.7/African American store– lowest in white neighborhoodslowest in white neighborhoods

99

Challenges for Tobacco Challenges for Tobacco ControlControl Lack of knowledge of health Lack of knowledge of health

effects of tobacco useeffects of tobacco use NAWHO, 1998NAWHO, 1998

– 1 in 5 Vietnamese did not know 1 in 5 Vietnamese did not know smoking causes heart disease, smoking causes heart disease, bronchitis, emphysema, COPD, and bronchitis, emphysema, COPD, and mouth cancermouth cancer

– 27% (1 in 4) Vietnamese adults did 27% (1 in 4) Vietnamese adults did not know smoking can cause cancernot know smoking can cause cancer

1010

Challenges for Tobacco Challenges for Tobacco ControlControl

““Little is known about levels of Little is known about levels of tobacco control awareness or tobacco control awareness or

attitudes and beliefs about attitudes and beliefs about tobacco in Asian American tobacco in Asian American

populations.”populations.”

National Asian Women’s Health Organization, National Asian Women’s Health Organization, 19981998

1111

Hold that thought…Hold that thought…

1212

Traditional Health Traditional Health BeliefsBeliefs

Vietnamese Americans commonly Vietnamese Americans commonly turn to traditional health beliefs in turn to traditional health beliefs in managing personal health, even if managing personal health, even if they use Western medicine they use Western medicine

1313

Vietnamese Health Vietnamese Health Project 2002Project 2002 PurposePurpose

– Identify cancer preventive behaviors Identify cancer preventive behaviors specific to Vietnamese American specific to Vietnamese American communitiescommunities

TeamTeam– Harborview Medical Center Harborview Medical Center – Refugee Immigrant Health ClinicRefugee Immigrant Health Clinic– Vietnamese Community CoalitionVietnamese Community Coalition– Fred Hutchinson Cancer Research CenterFred Hutchinson Cancer Research Center

1414

Project’s Theoretical Project’s Theoretical FrameworkFramework PRECEDE conceptual framework PRECEDE conceptual framework

used for potential determinants of used for potential determinants of smokingsmoking– Predisposing factors (traditional Predisposing factors (traditional

beliefs, knowledge, attitudes)beliefs, knowledge, attitudes)– Enabling (availability and access to Enabling (availability and access to

health services) health services) – Reinforcing (family, peer, medical Reinforcing (family, peer, medical

support)support)Green et al 91Green et al 91

1515

Methods: SamplingMethods: Sampling

Cross-sectional survey designCross-sectional survey design Addresses from 7 South Seattle zip codesAddresses from 7 South Seattle zip codes List of Vietnamese last names to identify List of Vietnamese last names to identify

Vietnamese households from phone bookVietnamese households from phone book Identified 1,639 householdsIdentified 1,639 households Randomly sampled n=900 householdsRandomly sampled n=900 households

– Interviewed one man and one woman (18-64 Interviewed one man and one woman (18-64 yrs) in each householdyrs) in each household

1616

Methods: RecruitmentMethods: Recruitment

Publicized surveys through posters in Publicized surveys through posters in communitycommunity

Mailed introductory letters to each Mailed introductory letters to each householdhousehold

Conducted interviews in respondents’ Conducted interviews in respondents’ homes using bilingual, bicultural homes using bilingual, bicultural interviewersinterviewers

Tokens of appreciation Tokens of appreciation – Original artwork depicting scenes from Original artwork depicting scenes from

VietnamVietnam– Summary of social and health resourcesSummary of social and health resources

1717

Methods: Instrument Methods: Instrument and Analysisand Analysis InstrumentInstrument

– Sociodemographic characteristics Sociodemographic characteristics (19-items)(19-items)

– Smoking (37-items)Smoking (37-items)– Traditional health beliefs (11 items)Traditional health beliefs (11 items)

AnalysisAnalysis– Descriptive statistics using STATA Descriptive statistics using STATA

7.07.0

1818

Results: DemographicsResults: DemographicsCooperation Rate: 82% Cooperation Rate: 82%

CharacteristicCharacteristic N = 509N = 509

Age (mean yrs,SD)Age (mean yrs,SD) 44 (12)44 (12)

Education (mean yrs, SD)Education (mean yrs, SD) 13 (3)13 (3)

Education level (%)Education level (%)

< 12 yrs< 12 yrs

12 yrs12 yrs

> 12 yrs> 12 yrs

2424

3131

4545

Born in Vietnam (%)Born in Vietnam (%) 9999

Proportion life spent in US (%)Proportion life spent in US (%) 30 30

Age at immigration (yrs, SD)Age at immigration (yrs, SD) 32 (13)32 (13)

1919

Results: DemographicsResults: Demographics

CharacteristicCharacteristic % (N = 509)% (N = 509)

Marital status Marital status

Currently marriedCurrently married

Previously marriedPreviously married

Never marriedNever married

8080

44

1717

English fluency (well/fluent) English fluency (well/fluent) 4848

Vietnamese fluency Vietnamese fluency 9797

Religion Religion

Buddhist and other AsianBuddhist and other Asian

Catholic or ProtestantCatholic or Protestant

NoneNone

5353

3939

88

2020

Results: DemographicsResults: Demographics

CharacteristicCharacteristic % (N = 509)% (N = 509)

Employment status Employment status

EmployedEmployed

UnemployedUnemployed7777

2323

Housing Housing

PublicPublic

RentedRented

OwnedOwned

1818

2626

5656

Have health insurance Have health insurance

YesYes

NoNo8585

1515

2121

Results: PrevalenceResults: Prevalence

VariableVariable % (N = 509)% (N = 509)

Smoking statusSmoking status

FormerFormer

CurrentCurrent

NeverNever

2626

3838

3636

Asked if smoked in last routine Asked if smoked in last routine check-upcheck-up

7272

Have friends who smokeHave friends who smoke 9494

2222

Results: KnowledgeResults: Knowledge

VariableVariable% Correct % Correct

(N = 509)(N = 509)

Smoking can cause lung cancerSmoking can cause lung cancer 9797

Second-hand smoke can cause lower Second-hand smoke can cause lower respiratory tract infections in childrenrespiratory tract infections in children

9696

Is addictiveIs addictive 9595

Second-hand smoke can cause lung Second-hand smoke can cause lung cancer in non-smokerscancer in non-smokers

8787

Causes heart diseaseCauses heart disease 8383

Second-hand smoke can cause heart Second-hand smoke can cause heart disease in non-smokersdisease in non-smokers

7676

Causes strokeCauses stroke 7070

2323

Results: AttitudesResults: Attitudes

VariableVariable % Agree % Agree

(N = 509)(N = 509)

Smoking not allowed anywhere Smoking not allowed anywhere inside homeinside home

9393

Smoking is widely accepted Smoking is widely accepted among men in Vietnamese among men in Vietnamese communitycommunity

8282

Appropriate for Appropriate for menmen to smoke to smoke with friendswith friends

3030

Appropriate for Appropriate for womenwomen to to smoke with friendssmoke with friends

22

2424

Results: AttitudesResults: Attitudes

VariableVariable % Agree % Agree

(N = 509)(N = 509)

Gifts of tobacco acceptable in Gifts of tobacco acceptable in Vietnamese communityVietnamese community

1616

Impolite to refuse cigarette by Impolite to refuse cigarette by hosthost

1313

Smoking makes Smoking makes menmen appear appear more sophisticated and more sophisticated and confidentconfident

1212

Smoking makes Smoking makes womenwomen appear appear more sophisticated and more sophisticated and confidentconfident

44

2525

Results: Traditional Results: Traditional Health Beliefs and Health Beliefs and Correlations with Current Correlations with Current SmokersSmokersVariableVariable % Agree % Agree

(N = 509)(N = 509)SmkSmk

CorrCorr

Illness Illness

-can be prevented by taking -can be prevented by taking herbsherbs

-can be prevented by -can be prevented by maintaining a positive attitudemaintaining a positive attitude

6565

8989++

--

-is a matter of karma or fate-is a matter of karma or fate

-is caused by imbalance of -is caused by imbalance of cold/heatcold/heat

18 18

7070++

++

Course of illness changed by faithCourse of illness changed by faith 6161 --

Some diseases caused by wind Some diseases caused by wind illnessesillnesses 5252

++

2626

Results: Traditional Results: Traditional Health Beliefs and Health Beliefs and Correlations with Current Correlations with Current SmokersSmokersVariableVariable % Agree % Agree

(N = 509)(N = 509)SmkSmk

CorrCorr

Some American medicines too Some American medicines too strongstrong

2626 --

Western medicine is as good or Western medicine is as good or more effective to treat more effective to treat

A.A. root causeroot cause of illness of illness

B.B. symptomssymptoms

5555

6363++

++

Should visit a Dr regularly even Should visit a Dr regularly even without problemswithout problems

9393 --

Coining is best treatment for Coining is best treatment for some illnessessome illnesses

5050 ++

2727

Traditional Health Beliefs Traditional Health Beliefs Independently Independently Associated with Current Associated with Current Smoking Smoking

OR 95%(CI)OR 95%(CI)

Some diseases are caused by Some diseases are caused by wind illnesseswind illnesses

1.6 1.6

(1.10, 2.33)(1.10, 2.33)

Illness is caused by imbalance Illness is caused by imbalance cold/heatcold/heat

1.7 1.7

(1.09, 2.69)(1.09, 2.69)

2828

Traditional Health Belief Traditional Health Belief Summary Msrs vs Summary Msrs vs Current Smoking StatusCurrent Smoking StatusIndependent variableIndependent variable OROR 95% CI95% CI

Strong/weak Strong/weak traditional health traditional health beliefsbeliefs

1.271.27 .88, 1.82.88, 1.82

Traditional health Traditional health belief scorebelief score

1.121.12 1.01, 1.231.01, 1.23

2929

SummarySummary

High prevalence of smoking among High prevalence of smoking among Vietnamese American menVietnamese American men

Strong traditional beliefs held Strong traditional beliefs held about healthabout health

Current smokers independently Current smokers independently associated with belief that associated with belief that – illness caused by wind illness caused by wind – illness caused by imbalance of illness caused by imbalance of

heat/coldheat/cold

3030

ImplicationsImplications

Little change in prevalence of smoking in Little change in prevalence of smoking in this community since 1995this community since 1995

Smokers may attribute poor health Smokers may attribute poor health especially to wind or cold/heat imbalance especially to wind or cold/heat imbalance insteadinstead

Smokers may believe that illness is fated, Smokers may believe that illness is fated, but that Western medicine will curebut that Western medicine will cure

Possibly identify risk in community using a Possibly identify risk in community using a summary score for traditional health summary score for traditional health beliefsbeliefs

3131

LimitationsLimitations

Generalizeability to other regions Generalizeability to other regions or to neighborhoods with smaller or to neighborhoods with smaller proportions of Vietnamese proportions of Vietnamese residentsresidents

Acquiescence bias Acquiescence bias Direction of causality Direction of causality

undetermined because of cross-undetermined because of cross-sectional nature of analysissectional nature of analysis

3232

Strengths of StudyStrengths of Study

Community-based sampling methodCommunity-based sampling method Use of theoretical model to guide Use of theoretical model to guide

projectproject First known study to look in depth at First known study to look in depth at

the associations between traditional the associations between traditional health beliefs and smoking status in health beliefs and smoking status in a high risk populationa high risk population

3333

Questions?Questions?

3434

Summary Scale for Summary Scale for Traditional Health Traditional Health BeliefsBeliefs

Pe

rce

nt

tradhsum1 11

0

26.3261