Knowledge of Tobacco Control Policies among U.S. Southeast Asians

Abstract

Some of the highest smoking rates in the U.S. have been reported among Southeast Asians. The largest numbers of Southeast Asians reside in California. While California has a comprehensive and generally effective tobacco control program, it is unclear how immigrant groups learn of this public health effort. In a study of tobacco norms and practices among two generations of Southeast Asians we collected qualitative data on respondents’ knowledge and awareness of tobacco control policies. Data were collected through in-person interviews with 164 respondents aged 15–87, evenly divided by smoking status, gender and generation in the U.S. Due to multiple sources of knowledge, general awareness of tobacco control policies and of secondhand smoke were high among both generations of Southeast Asians and the policies were attributed with changes in smoking behavior. Tobacco control regulations may be an effective means to impact tobacco use among immigrants with limited English proficiency.

Introduction

While past decades have seen reductions in smoking in the general population of the U.S., many subgroups continue to evidence problematic patterns of tobacco use. This is particularly the case for Asian Americans and Pacific Islanders (AAPI). Contrary to the stereotype of Asian Americans as the “model minority” in the U.S., high rates of smoking have been found among AAPI groups (1). Smoking among U.S. Southeast Asians has been reported at rates of 35–70% (2), with the highest rates among males. Evidence indicates that increasing length of time in the U.S. is associated with decreasing smoking prevalence among Southeast Asians (3). While changes in immigrants' tobacco use have been attributed to acculturation (4–6), the precise mechanisms by which socio-cultural context impacts tobacco use remain unclear. Tobacco control policies represent a unique aspect of the socio-cultural environment for tobacco use in that they can be identified and assessed far more easily than other less tangible aspects of the environment.

Tobacco control policies in California

In recent decades, California has lead the nation in tobacco control efforts, with high taxes on tobacco products and state laws prohibiting, for example, tobacco advertising in various settings, tobacco sales to minors, and smoking in workplaces and other public spaces. Of U.S. states, California has the second lowest adult smoking rate (7), which may be attributed to state tobacco control efforts (8,9). California, however, also has the highest percent of foreign-born residents of any U.S. state (27.2%) (10), including many immigrants with limited English abilities and poor access to preventive health care. Some researchers have attributed increased stigma around smoking in California with high quit rates among Asians (11). The role of tobacco control policies in quitting among ethnic minority populations, and particularly those who are underserved in health outreach and education, has been relatively unexplored.

Tobacco control policies have been shown to impact norms related to smoking (12) as well as the prevalence of smoking (13–15). Little is known, however, about the mechanisms by which the content and aims of these policies are apprehended and internalized by the public. Although these policies can be seen as milestones in the tobacco control movement, successful policy implementation may depend at least in part on the degree to which the underlying issues are understood and supported (16). Limited English proficiency has been found to be a barrier to immigrants’ access to healthcare in general (17–19) and to be significantly related to smoking among Asians in California (20). The few studies investigating Asian immigrants’ awareness of and attitudes towards tobacco have found some variation in their understanding of the health effects of smoking and mixed attitudes towards restrictions on tobacco use (21–23). There is little information, however, on how immigrants, Asian or otherwise, learn about such policies. As part of a study of tobacco use among two generations of Southeast Asians in Northern California, we collected data on respondents’ awareness of and sources of information regarding tobacco control policies. The results illustrate the means by which a linguistically isolated population may yet learn of public health policies.

Southeast Asians in California

By the time of the 2000 U.S. census, far more Southeast Asians resided in California than in any other state, including Laotians (55,456 or 32% of the total 168,707) and Cambodians (70,232 or 40% of the total 171,937) (24). Coming from agrarian backgrounds with little or no formal education, most Southeast Asians evidence little or no ability to speak English. Statewide, 56% of Cambodians and 55% of Laotians reported limited English proficiency, and 32% of all Cambodian and Laotian households are considered linguistically isolated (households in which no member 14 years or older speaks English “very well”) compared to 10% percent of all households in the state (25).

Tobacco is easily grown in most parts of Southeast Asia, and smoking is highly normative and figures centrally in social interactions in Southeast Asian culture. The children of Southeast Asian immigrants, however, have grown up in the context of U.S. society where cigarette smoking has been increasingly stigmatized in recent decades, particularly in California (26). Second-generation status has been identified as protective against smoking, particularly among females and less so among males (27), but this may vary by immigrants’ country of origin, particularly for Asian Pacific Islanders (28). While the reasons for these variations by generation have not been investigated, as an aspect of the social environment for tobacco use, tobacco control policies may well play a role.

Methods

Participants

The sample for this study included 164 Southeast Asians from two communities in the East San Francisco Bay Area. “Southeast Asians” here includes only persons from families originating in Laos or Cambodia. Table 1, below, describes the study participants.

Table 1.

Study Sample Characteristics

	Generation 1 N = 88	Generation 2 N = 76	Total N = 164
Mean age (s.d.)	49.2. yrs. (11.84)	19.3 yrs. (3.42)	35.4 (17.4)
Current smoker	48.9%	46.1%	47.6%
Current smoker mean age (s.d.)	52.1 yrs. (11.35)	19.6 yrs. (3.24)	37.8 (18.3)
Male	50.0%	50.0%	50.0%
Cambodian	68.0%	60.0%	49.4%
Laotian	32.0%	40.0%	50.6%
Born in U.S.	0%	72.0%	34.0%
Uninsured or MediCal	31.8%	52.7%	41.5%

The study sample included equal numbers of males and females representing two generations in the U.S. Respondents were recruited through agency referrals, personal contacts of the interviewers and snowball sampling. To assess the full range of knowledge and attitudes about tobacco use, respondents were also stratified by smoking status, with equal numbers of smokers and nonsmokers sought for each gender and generational category. The first generation respondents ranged in age from 30 to 87 years, with a median age of 49.2 (s.d. 11.84), and the second generation ranged in age from 15 to 28 years, with a mean age of 19.3 (s.d. 3.42). Of the first generation respondents, 81% reported using a language other than English as their primary language, while 20% of second generation respondents also reported this.

Data Collection

Because the research topics were relatively unexplored, qualitative methods were selected. While quantitative methods are useful for testing hypothesized relationships between a limited set of predetermined variables, qualitative methods are useful for discovering broad themes and identifying patterns and variations in social processes and human behavior.

Field interviewers conducted confidential in-person interviews with the respondents. Many interviews were conducted by Southeast Asian staffpersons from subcontracted community-based agencies. Qualitative data were collected through a semi-structured interview which included questions regarding tobacco use behaviors, social contexts of use, and perceptions and attitudes regarding tobacco use. Respondents were given the option of conducting the interview in English, Laotian or Khmer. All but a few of the first generation interviews were conducted in either Laotian or Khmer, while all of the second generation interviews were conducted in English. The semi-structured interviews were digitally recorded, translated where necessary and transcribed, and the transcribed recordings were loaded in the ATLAS.ti qualitative data management software (29) for coding and analysis. All data collection protocols were approved for the protection of human subjects by the research agency’s Institutional Review Board.

Measures and Data Analysis

The qualitative data were coded using a priori codes based on the research questions and category codes to identify respondents by sample strata. Using a horizontal-thematic approach whereby one theme was analyzed across all texts coded as related to policy (30), we identified three broad themes: Knowledge of tobacco control policies, Language as a barrier, Sources of information; and Consequences of tobacco control policies. We also compared responses within these themes by respondents’ generational and smoking status.

Results

Knowledge of tobacco control policies

Respondents reported awareness of state laws regulating tobacco sales and use. Of respondents who were asked what they knew of the laws regarding tobacco (61% of the first generation and 22% of the second generation), the majority from both generational groups (80% or more each) were able to demonstrate some knowledge of these laws. First generation respondents offered detailed knowledge in specific domains of tobacco control policy.

Prohibitions on smoking in public places

The responses related to knowledge of policies addressed prohibitions on smoking in public places, regardless of the respondents’ generational or smoking status. First generation respondents provided details about smoking prohibitions, noting for example that smoking was not allowed in public places like stores, hospitals, schools, airports and restaurants as well as on public transportation.

For the most part, it’s at hospitals. You definitely can’t [smoke] there. Hospitals, schools, inside schools you can’t [smoke] either. Now, you can’t smoke in restaurants either. Before, they had “smoking section” and “non-smoking section” but now they don’t have it anymore. (45 year-old male, current smoker; italicized texts in English in original)

Second generation respondents’ responses focused on the environments they most frequented, specifically school and work. Second generation respondents also mentioned that their employers did not allow smoking indoors, although they referred to these regulations as company policy rather than state law. Some noted that many employees disregarded these policies.

Age restriction on purchasing tobacco products

Respondents were aware that a person must be of a certain age to purchase tobacco products. Responses by smokers and nonsmokers alike were often related to personal experiences of underage purchase attempts by younger respondents or their friends. These respondents described the requirement to show identification to purchase tobacco products as well as ways to overcome this challenge, such as asking an available adult to make the purchase, looking “old enough,” as well as knowing which venues would sell to minors.

Language as a barrier

An overarching theme was language as a barrier to understanding the law. Respondents described older respondents in particular as being limited by their language ability, while ability to comprehend English was described as a reason that younger people might know more. Language ability impacted all aspects of source of information. For example, respondents described language as limiting their own ability or that of others to get information from the TV news. Respondents noted that not all Southeast Asians would be able to read signs posted in English, although signs signifying “no smoking” depicting a cigarette in a circle with a slash across it were considered to be more universally understandable. Our findings, however, indicate that though language barriers may have prevented many older respondents from fully apprehending the content of tobacco control policies, there was overall a high awareness of these policies. This was due to multiple sources of information being available.

Sources of information

Respondents described four sources of information from which they learned about tobacco control policies: news media, posted signs, word of mouth, and observing the behavior of others. First generation respondents listed the news and observing others as sources, while second generation respondents listed only the news. Both generational group cited word of mouth as a source of information.

News

First generation respondents noted they got their information about the policies from the news in either television or print form.

When the law was created, the TV announced it. It was also advertised in the newspapers. (38 year-old female, nonsmoker)

Second generation respondents who cited the news as a source of information, described getting their information from television or radio news than from the newspaper.

Signs

Respondents from both the first and second generation respondent groups cited “no smoking” signs in public places as their source of information about tobacco control policies. As would be expected, current smokers appeared to be particularly aware of these signs. Locations specifically mentioned included restaurants, hospitals, schools and public transportation. Respondents generally mentioned signs in reference to knowing an area was not a “designated” area because of the “writing on the wall.”

Around the city and around these places there are signs posted [that say] “No smoking.” (80 year-old male, current smoker)

Additionally, second generation respondents reported signs associated with the purchasing age of tobacco products.

The law is really easy to remember because they have a goddamn sign right there that tells you in the store, “prepare to show ID if you’re under the age” -- if you look under the age 25, or y’know, 18, whatever. You gotta be 18 to buy cigarettes or whatever, and you can’t smoke underage, or you can’t sell ‘em. (17 year-old female, nonsmoker)

Word of mouth

Respondents from all sample strata described learning about the existence of tobacco control policies from other people, with first generation respondents particularly citing their children as their source of information.

My kids would let me know. They would tell me that smoking isn’t allowed at certain places. I learn these things from the kids. (60 year-old male, current smoker)

In other cases, respondents described hearing about laws from friends and acquaintances. Second generation respondents’ descriptions of social sources of knowledge were not as specific as their elders’. Second generation respondents usually noted that “someone” told them about it at school, such a teacher or a police officer (during an in-school drug prevention presentation). In some cases the sources of information appears to have been clerks from whom the respondent was attempting to purchase cigarettes. Others sources were unattributed.

Observing the behavior of others

Respondents also discussed knowing about the state anti-tobacco policies without having learned from any source in particular. Instead, they attributed their understanding of rules about smoking to simply observing where ashtrays were or were not located, or where others were or were not smoking.

If it doesn’t have an astray inside, then you know you can’t smoke inside. [I: Where did you learn about this law? Did you hear people talking about it, or see it on TV?] No, I just noticed it myself. (55 year old male, former smoker)

Consequences of tobacco control policies

Respondents noted that tobacco control policies were responsible for changing cultural traditions around the use of cigarettes as gifts to guests at events such as weddings, which would frequently be held at restaurants in the U.S.

That [gifting of cigarettes] doesn’t happen anymore. They no longer hand out cigarettes, because the restaurants prohibit smoking. Moreover, a lot of people have quit smoking. (40 year-old male, current smoker)

Respondents also noted that the prohibitions on public smoking had had the positive effect of encouraging smokers to quit:

Smokers are now the minority. Smoking laws are increasing in numbers, and stricter than before. So much so that smokers are reducing their numbers of cigarettes, some have even quit smoking. It’s difficult for them to smoke these days, so they just quit. Everywhere you go, smoking is prohibited. Hence, it’s easier to just quit smoking. Some people work and want to smoke. However, their jobs are more important, so they continue working and gradually give up the habit until they quit altogether. (51 year-old male, current smoker)

Discussion

Although the smoking prevalence rates among Southeast Asians in the U.S. have been shown to be very high, most of our respondents were knowledgeable about California tobacco control policies, regardless of generation in the U.S. While language did emerge as a barrier to knowledge in discussions of the laws, information about tobacco control policies had permeated the socio-cultural environment of this community to the degree that most could be said to know something about the laws. This was due not only to formal information dissemination such as signs and news reports, but perhaps more importantly to direct experiences with the laws—regulations at school and worksites and at point of sales locations—and through conversations with others in their social circles.

Word of mouth was a particularly important source of information for respondents with limited English abilities. While they may not have fully comprehended the tobacco control laws, conversations with their children and others appeared to have provided these respondents with the minimum amount of information needed to understand the gist of the laws. Similarly, while they could not necessarily read news articles or posted signs, nonverbal signage made the prohibitions on public smoking more immediately accessible to limited English speakers.

Although Southeast Asian immigrants may be considered socially isolated due to their limited English and limited access to work and school, many of our first generation respondents described sources of information associated with the social environment outside the home, such as restaurants, hospitals, buses and their children or grandchildren’s schools. This indicates that while limited English proficiency may be a barrier in their access to a great deal of healthcare information, the public nature of tobacco control regulations may result in higher access to these public health policies than to health information per se for immigrants. As noted by our respondents, reducing and quitting smoking among Southeast Asian immigrants may therefore be as or more related to social environmental effects like smoking restrictions as to an increased awareness of the harmful effects of tobacco use.

The sources of information for our second generation respondents were also associated with public spaces, but these younger respondents appear to be more aware of point of access information, such as the convenience and liquor stores where they seek to purchase cigarettes, than information regarding restrictions on public smoking. A recent U.S. study of a multi-ethnic sample of youths found them to be generally aware of, although skeptical towards, many forms of tobacco control policy (31). Very little research has otherwise been done on youths’ awareness of tobacco control policies. Prevention and reduction of smoking among youths are critical, as most smokers develop the habit of smoking in this period of their lives. More attention should be placed on the role of social environmental factors such as tobacco control policies in curbing youthful smoking, particularly among groups, such as Southeast Asians, with high rates of adult smoking.

Recent research has found some Asian immigrants to be disproportionately left out of the intended benefits of some tobacco control policies, such as workplace smoking ordinances in restaurants and bars (32, 33). The findings of this study indicate, however, that such restrictions may have an overall and cumulative effect of raising smokers’ awareness of their habit and its effect on others as well as on their own health. A recent study of the influence of smoking bans on smoking prevalence has found correlations between such bans and the stages of change in smokers’ quit attempts, indicating that tobacco control policies do have an impact on smokers’ consciousness (34). This indicates the importance of tobacco control regulations for immigrants with limited access to healthcare information and for youthful smokers whose attention to health information may be limited as well.