A Qualitative Exploration of the Tobacco Control Needs of Colorado Asian American Pacific Islanders

1
A Qualitative Exploration of the Tobacco
Control Needs ofColorado Asian
AmericanPacific Islanders
2

• A Priority Population Statewide Needs Assessment
• Conducted for the
• Colorado State Tobacco Education and Prevention
  Partnership (STEPP)
• By Asian Pacific Development Center and
• OMNI Research Training

3
Overview

• Section 1 Background
• Section 2 Needs Assessment Process
• Section 3 Key Findings

4
Section 1

• Background

• History of STEPP
• Overview of AAPI Population in Colorado
• Overarching Goal and Focus of the Tobacco Control
  Needs Assessment among AAPIs

5
History of STEPP

• In 1995, Colorado, along with 46 other states,
  filed suit against tobacco companies.

• On November 23, 1998, parties agreed to the
  Master Settlement.

• Colorado was awarded 42.6 billion over 25 years,
  15 of which was allocated for tobacco education,
  cessation and prevention.

6
History of STEPP

• Beginning in June 2001, needs assessments were
  conducted to determine the unique tobacco
  education, cessation and prevention needs of 8
  priority populations in Colorado
• African Americans
• Native Americans
• Asians and Pacific Islanders
• Latino/Hispanic
• Gay, Lesbian, Bisexual and Transgendered Persons
• Spit Tobacco Users
• Persons in Treatment for Substance Abuse
• Persons with Mental Illness Who Use Tobacco

7

• The Asian American Pacific Islander Population in
  Colorado

8
The AAPI Population in Colorado

• The 2000 Census counted 95,213 Asian Americans
  and 4,621 Pacific Islanders in Colorado.

• AAPIs comprise 3.1 of the States total
  population when one includes individuals who
  categorize themselves as AAPI in combination with
  another racial ethnic group.

9
2000 Census Data on Major Colorado Asian Ethnic
Groups
 
 
Source U.S. Census Bureau, Census 2000  
10
2000 Census Data on Major CO Pacific Islander
Ethic Groups
 
 
 
 
Source U.S. Census Bureau, Census 2000  
11

• Tobacco Control Needs Assessment among Asian
  American Pacific Islanders

12
Tobacco Control Needs Assessment among Asian
American Pacific Islanders

• Goal To initiate culturally appropriate
  research that would inform public health
  strategies to

1. Reduce initiation of tobacco use by youth
2. Reduce exposure to environmental tobacco smoke
3. Promote cessation among AAPI youth and adults
13
Tobacco Control Needs Assessment among Asian
American Pacific Islanders

• To accomplish this goal, the needs assessment was
  designed to address two fundamental questions
  about AAPI use

1. What are the social meanings and cultural
practices that surround tobacco use by AAPIs?
2. How does nation of origin influence social
and cultural acceptance of tobacco use and
different forms of tobacco use?
14
A Note about the Qualitative Nature of this Needs
Assessment

• Qualitative investigation permitted partners to
  gain a deeper understanding of the social and
  cultural context of tobacco use among AAPIs.

• This context, together with information about the
  perceived prevalence of tobacco use and current
  level of concern in communities about tobacco
  use, provided important data to inform the
  development of culturally appropriate public
  health interventions.

15
Section 2

• Needs Assessment Process

• Overview of Major Components
• Partnerships and Relationships Leveraged
• Peer-to-Peer Research Model

16
Needs Assessment Process

• Involved 4 distinct components

1. Health care practitioner interviews
2. Engagement of bicultural and bilingual
peer-to-peer researchers
3. Community member interviews
4. Establishment of the Colorado AAPI Tobacco
Advisory Board
17
Needs Assessment Process

• At each stage, members of AAPI communities played
  key roles in

• Informing content areas to explore

• Informing the development of instruments

• Recruiting participants

• Collecting and translating data

• Contributing to data interpretation

• Informing the development of statewide
  recommendations

18
Participatory Research Model
19

• Health Practitioner Interviews

20
Health Care Practitioner Interviews

• Research began with this group for the following
  reasons

• Assumed to be relatively more assimilated (might
  enhance ability to be more reflective of social/
  cultural determinants of tobacco use)

• Identify salient issues to explore in more depth
  through interviews with community members

• Could alert researchers to any sensitive areas
  before approaching communities (enhanced the
  cultural competence of research)

21
Topics Explored inHealth Care Practitioner
Interviews

• Perspectives on the prevalence of tobacco use
  among AAPIs
• Barriers to Health Care Access
• Cultural appropriateness and acceptance of widely
  used methods of cessation
• Culturally appropriate alternatives for promoting
  prevention and cessation

22
Sample

• 14 Health Care Practitioners
• At least 4 major ethnic groups represented
• Korean (4)
• Chinese (4)
• Vietnamese (2)
• Pacific Islander (2)
• Unknown (2)

23
Sample

• Represented varied areas of expertise in the
  health care field including
• Mental Health (e.g., counseling, clinical
  psychology)
• Alternative Medicine (e.g., acupuncture)
• Dentistry
• Nursing
• Pediatrics
• Family Medicine

• 6 of the health care professionals interviewed
  had trained and/or practiced outside of the
  United States.

24

• Peer-to-Peer Research Model

25
Peer-to-Peer Researchers

• Represented 9 Asian ethnic communities

• 1 male and 1 female peer researcher were
  recruited from each of these communities
• In 3 Asian communities, female peer researchers
  conducted interviews with both males and females

26
Training to Support Peer Researchers

• Recruitment
• Recording equipment
• Interviewing Tips
• How to build rapport
• How to use probes
• Challenges
• Interview Protocol and Checklist
• Research Ethics
• Voluntary nature of participation
• Confidentiality

27

• Community Member Interviews

28
Topics Explored inCommunity Member Interviews

• Knowledge, attitudes, beliefs, and values
  surrounding tobacco use
• Social and cultural settings/circumstances of
  tobacco use
• Perceptions about the prevalence of tobacco use
• Effects of tobacco use

29
Sample Community Member Interviews

• Peer researchers were asked to recruit
• Caregivers of individuals with tobacco-related
  illnesses

• Adults who use tobacco

• Parents of youth that use tobacco

• Recent immigrants

• Individuals that are concerned about tobacco use
  within their ethnic community

30
Sample Community Member Interviews

• A total of 72 interviews were conducted by peer
  researchers
• Duration of interviews ranged from 20 minutes to
  over one hour
• Nearly 2/3 of these interviews were conducted in
  an Asian language

31
Peer-to-Peer Researchers

• A small group of peer researchers convened to
  debrief the interview process

• During the debrief, peer researchers were
  encouraged to reflect on
• the interview process,
• their own personal experiences, and
• to identify new areas for further exploration.

32

• Establishment of the Colorado AAPI Tobacco
  Advisory Board

33
AAPI Tobacco Advisory Board

• Provided feedback on emerging findings from the
  needs assessment

• Ensured interpretations were culturally
  appropriate and represented/articulated
  accurately

• Provided further reflection on the tobacco
  control needs of AAPI communities

• Began to identify culturally appropriate tobacco
  control methods and messages

34
Participatory Research Model
35
Section 3

• Findings

• Social and Cultural Context of Tobacco Use among
• AAPI Men
• APPI Women
• AAPI Youth
• Cultural Tensions and Nuances
• Health Beliefs Influencing Smoking Behavior

36
Social Acceptance of Smokingamong AAPI Males

• A big part of our culture, especially for males,
  is to smoke. I feel thats probably one of the
  big reasons why Vietnamese people smoke is
  because to be a man and stuff, you have to
  smoke.

37
APPI Males and Tobacco Use

• In general, tobacco use is more widespread and
  socially accepted among males

• Smoking, in particular, has become part of the
  ritual of important social and cultural events

• Smoking is associated with social-economic
  attainment and Westernization

38
Social and Cultural Context of Smoking
Weddings

• In China, at weddings, there are many who smoke
  together. In fact, there are celebrations and
  ceremonies in which the bride offers others to
  smoke.

39
Social and Cultural Context of Smoking
Weddings

• During the Hmong wedding ceremony, they always
  handed cigarettes to one another according to
  Hmong culture.

40
Social and Cultural Context of Smoking
Business

• Any kind of business that you do with anybody,
  you have to provide them with cigarettes.

41
Social and Cultural Context of Smoking
Business

• In the Japanese community, especially with men,
  business is conducted with alcohol and smoking, a
  lot And, if you dont join in, thats not a
  good sign.

42
Social and Cultural Context of Smoking
Honoring or Greeting Guests

• Offering smokers cigarettes is symbolic of
  honor for them.

43
Tobacco Use and Its Relationship to
Socio-Economic Status

• In countries of origin, smoking has come to be
  associated with social status and has become part
  of the persona of a successful, professional
  male.

• Being able to afford cigarettes, particularly
  American brands, is seen as an indicator of
  relatively higher economic attainment.

44
Symbol of Socio-Economic Status

• Many immigrants grew up with intense marketing
  campaigns in their environments for tobacco.
  Tobacco is often seen as a luxury item, such a
  brandy. It is seen as a neat foreign thing.

45
Symbol of Socio-Economic Status

• Especially the upper middle and upper class, it
  is a bit of a status symbol. The lower and
  lower-middle class smoke cheap cigarettes and
  chew lots of tobacco leaves.

46
Cultural Conflict or Tension

• In addition to having to adjust to a new language
  and social environment, recent immigrants must
  also adapt to very different messages about
  tobacco use.

• Stigmatization of smoking

• Physical Isolation of smokers from non-smokers

47
Tobacco Use May Intensify the Social Isolation of
AAPIs in US

• I feel sorry for Asian Americans who immigrate
  here, who have never been exposed to American
  mass media public education and are stigmatized
  without receiving any education.

48
Prevalence Versus FrequencyDaily Versus
Occasional Use

• In prevalence studies, current smoking (or
  cigarette use) is defined as having smoked at
  least 100 cigarettes in ones lifetime and
  currently smoking.

• Although the prevalence of tobacco use (smoking)
  declines as AAPIs become more acculturated, the
  needs assessment found that tobacco use remains
  common for men at many cultural celebrations and
  social gatherings.

49

• Social Context of Tobacco Use among AAPI Women

50
Social Context of Tobacco Use among AAPI Women

• Traditionally, and in countries of origin, there
  are strong social sanctions against smoking among
  women

• Negatively affects her marriageability

• Reflects negatively on her family

51
Social Sanctions Prohibiting Smoking among AAPI
Women

• In Laotian culture, it is not acceptable for
  the women to smoke. They look down on you, and
  you feel ashamed, and its kind of bad. They
  look at you like a prostitute or something if
  you smoke.

52
Social Sanctions Prohibiting Smoking among AAPI
Women

• They talk about whos going to make a good wife
  and not a good wife. That is not the kind of
  thing that you want to display as a young women
  It looks crude. It looks disrespectful to your
  family It is a reflection of your parents, your
  heritage Your communitys opinion matters.

53
Social Sanctions Prohibiting Smoking among AAPI
Women

• Ive always had the impression from my parents,
  my community that it was just was not proper
  for young women to smoke. It was just not
  something that you did Like, it was something
  that was more acceptable for the older women.

54
Betel Nut Chewing among Older Asian/Pacific
Islander Women

• When women in some cultures reach a certain age,
  it becomes acceptable for them to chew betel nut.

• Betel Nut an addictive substance used in Asia

• Fruit of Areca catechu

• Usually sprinkled with calcium oxide, salt and
  powdered root of liquorice and wrapped in a
  tobacco leaf

55
Betel Nut Chewing among Older Asian/Pacific
Islander Women

• For my around my age (40 and up), we women
  can chew tobacco and then we eat the chestnut
  Asian, mostly women, choose that. That is more
  acceptable than smoking.

56
Betel Nut Chewing among Older Asian/Pacific
Islander Women

• Because from 40 up, women in Cambodia think that
  your mouth is kind of plain white. They want
  to see a little red in your mouth. Like you have
  lipstick. They dont use lipstick They eat
  that leaf, and their mouth becomes red.
  Then, it looks white and red.

57
Cultural Conflict or Tension

• Strong social norms against cigarette smoking
  among women in many countries of origin

• Strong social norms in the US against tobacco
  chewing among women

• Questions for future research

• How do recent immigrant women negotiate the
  cultural clash over the gender appropriateness of
  tobacco chew (by Asian women versus American men)?

• How do these conflicting social norms impact
  tobacco use among AAPI women?

58

• Social Context of Tobacco Use among AAPI Youth

59
Social Context of Tobacco Use among AAPI Youth

• Parental smoking was identified as a major factor
  influencing smoking among AAPI youth

• Modeling of the behavior

• Enhanced accessibility

60
Social Context of Tobacco Use among AAPI Youth

• Widespread, targeted marketing to youth, as well
  as the accessibility of tobacco products, are
  issues that AAPI youth confront in Colorado, just
  as the parents and other relatives may have in
  countries of origin

61
Social Context of Tobacco Use among AAPI Youth

• If you go down to Federal Boulevard, there is
  tobacco advertising everywhere. I can go to a
  store on Federal and buy loose tobacco. I went
  to an Asian market, and they were selling loose
  tobacco in a plastic bag Its too accessible
  for young people.

62
Cultural Conflict or Tension

• Low self-esteem and feelings of hopelessness are
  issues the many AAPI youth confront

• Many AAPI youth experience intense social
  isolation, as they feel caught in a cultural
  divide

• The absence of a cultural and social connection,
  and resulting issues of identity formation, may
  leave many AAPI youth vulnerable to negative peer
  pressures, such as smoking

63

• Health Beliefs Influencing Smoking Behavior

64
Health Beliefs Influencing Smoking Behavior

• Smoking as a mechanism for coping with stress

• Smoking is not harmful if there are no
  pre-existing health conditions

• Pre-destination

65
Coping with Stress

• When asked about the factors that put AAPIs at
  increased risk for tobacco use, many talked about
  the emotional and psychological stress
  experienced due to social isolation, resulting
  from language barriers and prejudice.

• Health care providers, in particular, described
  how AAPI use smoking as a means to cope with and
  reduce stress.

66
Coping with Stress

• Some Asians may live in their own community and
  may not feel a part of the larger society. This
  creates emotional stress -- the sense of not
  belonging. This may increase smoking.

67
Coping with Stress

• New immigrants think that if they use tobacco, it
  will help them with psychological problems
  (stress, culture, job, relationships, etc.).

68
Coping with Stress

• Well, I feel that the persons who are
  accustomed to smoking cigarettes feel When
  they have a cigarette, they feel good. If they
  do not have a cigarette, they feel stress or
  unhappy.

69
Who is Susceptible to Tobacco-Related Illness

• Smoking causes cancer. But, if you smoke in a
  healthy way, I think its okay. Well, it is
  usually But, if somebody does not have good
  health, when they smoke, they may have some
  problems. If somebody who has good health, if
  they smoke, they are okay. There is no problem.

70
Who is Susceptible to Tobacco-Related Illness

• People have this fatalistic attitude that your
  life is your life and it set up I dont think
  that, from my experience and in my family, that,
  you know, smoking would change your life. If you
  have an illness, youre going to have an illness.

71

• For more information about STEPP and how to
  obtain a copy of the report please contact

Gloria Latimer Director of Community
Programs STEPP [phone] gloria.latimer_at_state
.co.us