Perspectives of Chinese American Smoker and Nonsmoker Household Pairs about the “Creating Smokefree Living Together” Program

Abstract

Background

Chinese men smoke at high rates, putting household members at risk for tobacco-related diseases. Culturally responsive interventions that provide education and support are needed to promote smokefree living and reduce smoke exposure, particularly for US immigrants who experience changes in smokefree social norms. This qualitative study examines perspectives of Chinese American smoker and nonsmoker household pairs on the “Creating Smokefree Living Together” Program.

Methods

Four focus groups were conducted with 30 Chinese American participants (15 smokers, 15 nonsmokers) who, in household pairs, completed smokefree education interventions of either brief or moderate intensity. Nearly three-quarters of smokers continued to smoke post-intervention at time of focus group participation. All smokers were male and most household nonsmokers were female spouses. All participants had limited English proficiency. Focus groups were recorded, translated, and transcribed. Transcripts and field notes were thematically analyzed.

Results

The following themes, shared by smokers and nonsmokers across interventions, were identified: 1) preference for dyadic and group interventions because of the support offered, 2) increased knowledge of health harms of smoke exposure within the pair improved nonsmokers’ support for smokefree living, 3) learning communication strategies improved household relationships and assertiveness for smokefree environments, 4) biochemical feedback was useful but had short-term effects, and 5) project magnets provided cues to action.

Conclusions

Involving household partners is critical to smokefree interventions. Simple reminders at home appeared to be more powerful than personal biochemical feedback of smoke exposure for sustaining motivation and engagement in ongoing behavior change within the household.

INTRODUCTION

The most common cause of cancer mortality among Chinese Americans is lung cancer.¹ High smoking rates have been observed for men who immigrate from China, where over half of men smoke.² A California-based study found that Cantonese-speaking Chinese men smoked at higher rates than Chinese men in general (21.7% vs. 14.2%).³ Despite tobacco control efforts, recent studies have found that nearly one-third of Chinese Californian men with limited English proficiency continue to smoke.⁴ In contrast, foreign-born Chinese American women smoke at very low rates,^{5, 6} but are at risk for secondhand smoke exposure if living with smokers.

The household is an important yet underexplored context to promote smokefree living. Having a smokefree home is associated with smoking cessation among Asian immigrants.⁷ Most Asian American households have smoking bans, yet particularly among less educated Asian women, enforcement of smokefree bans is challenging.^6,7 In addition to setting smokefree norms in the household, evidence suggests that family members provide important support for cessation. ^{8, 9, 10}

Greater education and support is needed for both smokers and nonsmokers^{9, 11} to counter inaccurate beliefs about the health consequences of smoking and secondhand smoke exposure and promote more constructive household communication to support individual smokers’ cessation efforts.¹² Although some interventions target smoking parents on behalf of children,¹³ only two published intervention trials have targeted smokers and nonsmoker family members.^{10, 14} Household-based interventions involving both smokers and nonsmokers may be particularly effective for those from collectivistic cultures given the importance of family harmony and emerging evidence that smoking can strain household relationships and reinforce smoking. ^{10, 11} The present study examined perspectives of Chinese American smokers and nonsmoker household members on acceptable and effective intervention strategies based on their experience participating together in the “Creating Smoke-Free Living” trial (see Tong et al. in this issue).

METHODS

Study Design and Recruitment

This study involved a partnership with Chinatown Public Health Center (CPHC), a San Francisco county clinic serving majority Cantonese-speaking Chinese immigrants, and three academic partners. Participant recruitment and study implementation was conducted at CPHC. IRB approval was obtained through UC Davis. Informed consent was obtained from participants prior to study participation.

Adult household pairs were recruited within six months of completion of a randomized controlled study comparing effectiveness of a moderate- vs. brief-intensity smokefree educational intervention for Chinese Americans. The larger study’s inclusion criteria were Chinese American adult pairs living in the same household with a male current smoker and a household nonsmoker. For this study, smokers and nonsmokers were purposively recruited to reflect both study groups and diversity in smokers’ smoking status at 12-month follow-up. Participants in both groups were enrolled in the trial over a 12-month period and completed multiple assessments. By 12-month follow-up, participants in both groups had received information on in-language smoking cessation resources, including the California Smokers’ Helpline (a free statewide cessation telephone counseling service available in Mandarin and Cantonese) and cessation classes offered by CPHC, an educational booklet created by the research team, and biochemical feedback of smoke exposure for both smokers and nonsmokers at three months. The biochemical feedback was a personalized report showing a color-coded graphical display of NNAL (a tobacco-specific carcinogen that reflects exposure in the past 1–2 months) results with tailored motivational messages. All participants received a house-shaped project magnet, which included a no-smoking graphic. Additionally, those in the moderate-intensity group received two group educational sessions in pairs facilitated by a health educator (third author) and three follow-up personal calls.

Focus group discussion format was selected by the research team so that cues from those in similar experiences might generate more in-depth discussion. Components of the Health Belief Model¹⁵ and Transtheoretical Model of Change¹⁶ in addition to multidisciplinary (i.e., internal medicine, psychology, sociology, public health) team discussion were used to create questions. Questions were designed to elicit feedback on intervention components, how smokefree behaviors and household dynamics changed with intervention participation, and suggestions for modifications. The same questions were asked in each group, e.g., “What changes, if any, have you observed in the smoking behavior (yours or your partner’s) in your family since you participated in the study?,” and “What about the program was most helpful or most difficult?” Moderate-intensity intervention participants were also asked about components specific to that intervention.

Four 1.5 hour-long focus groups, each with 6–9 participants, were conducted at CPHC and audio-recorded. All focus groups were facilitated in Chinese (i.e., Cantonese and Mandarin) by the third author, who has more than 30 years’ experience working with the Chinese community and extensive experience conducting focus groups. The facilitator emphasized that all viewpoints were welcomed and that participants need not agree. Additionally, she called on participants who had not provided their perspectives. Another bilingual CPHC staff was present to take notes during each focus group. Each participant received a $40 gift card for participation.

Data Analysis

Bilingual/bicultural transcriptionists translated the recordings into English, and then staff involved in data collection reviewed the translated transcripts for accuracy. Guided by the study aims and theoretical models, two investigators (AS and DP) independently conducted close readings of each transcript and field notes and generated initial codes. Using an iterative process, they then reviewed and compared codes and generated candidate themes.¹⁷ Each theme was further iteratively refined by discussion and consensus by all study team members.¹⁸ During group discussion, negative cases were carefully discussed and documented, and verbatim quotes used. Subgroups were analyzed separately and differences in the data were acknowledged in our findings.

RESULTS

Table 1 displays characteristics of the participants (15 smokers, 15 nonsmokers). Ten smokers and 10 nonsmokers participated in the interventions as household pairs; the remaining participated in the current study without their household partners due to scheduling conflicts. Eight smokers (53.3%) and 9 nonsmokers (60%) had participated in the moderate-intensity intervention.

Table 1.

Participant Characteristics

	Smokers, n (%) or mean (SD, range)	Nonsmoker Household Members, n (%) or mean (SD, range)
Gender
Male	15 (100%)	0
Female	0	15 (100%)
Age	61.0 (11.82, 43–82)	56.53 (15.27, 33–82)
Born outside of US	15 (100%)	15 (100%)
Years lived in US	9.87 (10.76, 0.33–42)	10.09 (11.42, 0.08–42)
English proficiency
Speak English not too well or not at all	13 (86.67%)	11 (73.33%)
Speak English so-so	2 (13.3%)	4 (26.67%)
Education
No formal education	1 (6.67%)	1 (6.67%)
Less than high school	5 (33.33%)	5 (33.33%)
High school graduate	7 (46.67%)	9 (60.0%)
Some college	1 (6.67%)
College graduate	1 (6.67%)
Relationship to nonsmoker household member
Spouse	14 (93.33%)	N/A
Parent	1 (6.67%)
30-day self-reported smoking status: changes from baseline to 12 months
From non-daily to 30-day abstinent	4 (26.67 %)	N/A
(biochemically verified)	2 (13.33%)
From daily reduced to non-daily	6 (40.67%)
No change: remained smoking daily	2 (13.30%)
No change: remained smoking non-daily	1 (6.67%)
From non-daily increased to daily smoking
Secondhand smoke exposure at home: changes from baseline to 12-month
From being exposed at home to no exposure	N/A	2 (13.30 %)
No change: no home exposure		13 (86.67%)

We identified five themes across smokers and nonsmokers participating in both moderate- and brief-intensity interventions of the “Creating Smokefree Living Together” program: 1) preference for dyadic and group interventions because of the support offered, 2) increased knowledge of health harms of smoke exposure within the pair improved nonsmokers’ support for smokefree living, 3) learning communication strategies improved household relationships and assertiveness for smokefree environments, 4) biochemical feedback was useful but had short-term effects, and 5) project magnets provided cues to action. Substantive differences in perspectives among participants in the two interventions were not detected, but negative cases are noted below.

Theme 1: Smokers and Nonsmokers Preferred Dyadic and Group Interventions Because of the Support Offered

All participants across intervention groups reported preference for interventions that involved both smokers and nonsmokers rather than one-on-one smoker-only interventions. Smokers felt that it was helpful to have their nonsmoker wives join the intervention. When asked about preferences, one smoker replied, “It is good, because when I take out a cigarette, she would say, ‘Why do you smoke that much?’ I put it back immediately.” Although all participants received information about the in-language quitline, only a few called. Those participants complained of the difficulty connecting with a counselor and therefore did not follow-through with the service. One smoker stated, “Sometimes, they don’t have someone who speaks [Cantonese] Chinese, then they speak English. Or if you don’t speak English, then they transfer you….The process is annoying.”

Subtheme 1.1: Nonsmokers varied in preference for dyadic vs. group interventions

Although there was overwhelming preference for involving nonsmokers in interventions, there were some variations among nonsmokers across groups in terms of preference for smokers and nonsmokers convening separately or together. Some participants preferred smokers and nonsmokers participating together and in larger groups because they felt encouraged hearing of others’ successes in behavior change. One nonsmoker said, “All of us spoke for a bit, and he listened, for example, [this man] stopped smoking, and how did he quit smoking…. For us, as husband and wife, we can compare this with other pairs.” Other nonsmokers felt that in group settings, smokers would lose face because they do not want nonsmoker partners comparing them to others. These nonsmokers felt that they and their smoker partners could be more honest if separated by gender and smoking status.

Subtheme 1.2: Nonsmokers preferred interventions led by a professional

Nonsmokers across groups felt that having a professional lead the intervention was more effective than their own support for the smoker. For example, one nonsmoker stated: “If the wife relied on what the teacher said, then the husband can remember it more…. Because if you talk to them, they would listen. If we talk to them, it seems like we have problems. No one likes to be criticized.” Nonsmokers attributed this to “saving face,” a cultural expression of protecting one’s social standing: “[The husband] says you do not give him face. Men need face….Many men are like that. It might be due to the Chinese culture, men want to be in charge of things.” Nonsmokers expressed that having a person with authority communicate to their smoker household partner buffered against smokers’ negative reactions to criticisms of their smoking.

Theme 2: Increased Knowledge of Health Harms of Smoke Exposure Within the Pair Improved Nonsmokers’ Support for Smokefree Living

Most smokers and nonsmokers across groups stated the importance of having household nonsmokers receive the same intervention so that they can better provide support. Participants described how learning the same materials helped nonsmokers better keep smokers accountable for behavior change. For example, one nonsmoker wife stated: “[Smoker] comes here by himself versus you go with him is not the same….If he comes here on his own, you don’t know what information he is getting. You cannot nag or complain about him. But if we both join together, then we will get the same information and learning.” Another nonsmoker said, “After they joined the program together, the wife can monitor and discipline him. She can remind him what they have learned in the program….Compared to one person joining the program by himself, two people joining together has a bigger effect.”

Some smokers noted that their household partners became more proactive in discouraging their smoking based on increased knowledge about the health harms of smoke exposure: “For me, it is helpful for my wife to come. From joining your presentations, she thinks that smoking is hazardous for the body. She supervises and urges me to not smoke.” Another similarly expressed,

[My wife] is different. After she joined this project, she knows that smoking is not good. The first thing she said is to smoke less, and quit slowly. “It is not good for the kids.” It is different now. The way she says it. It is different from others [who may say,] “Oh, you smoke. It smells bad....” She knows what is smoking and the harmfulness of it. Before, it is not like she doesn’t know it, but she doesn’t like the smell of smoke.

Theme 3: Learning Communication Strategies Improved Household Relationships and Assertiveness for Smokefree Environments

Across intervention groups, nonsmokers and smokers reported improved household relationships and assertiveness for smokefree environments, although this was more salient for participants who received the moderate-intensity intervention. Nonsmokers and smokers who received the moderate-intensity intervention were taught specific strategies to enhance communication about smokefree behaviors; nonsmokers were taught how to assert preference for smokefree environments and smokers were taught strategies to decline offers of cigarettes. A majority of smokers reported that relationships with their family members improved after both joined the intervention. One smoker (moderate-intensity intervention) noted, “My wife loves me more. Because there is no bad smell anymore.” Smokers in the brief-intensity group similarly stated, “[My wife] likes me more” and “It is good for your wife….It is good for you, and makes your wife happy.” In both intervention groups, smokers and nonsmokers noted that they engaged in more open conversations and that when nonsmokers encouraged smokers not to smoke, they were not perceived as nagging but rather expressing their concern for smokers’ health. For instance, one nonsmoker (moderate-intensity intervention) said, “[My husband] can hear about my opinion and I can hear about his opinion as well, it is the best for us. Because I know what he talked about, so when I went home, I could talk to him about the problems. If I did not hear about his opinion, I did not know what he said. Maybe he lied to me, [participants laugh] because I was not here.” Several smokers noted that because they know that smoking is not good, they do not argue with their wives about their smoking. In the moderate-intensity intervention smoker focus group, a participant stated, “At most, I would just smile and say to her, ‘Don’t be too harsh, okay?’” Another smoker followed up, “If she takes away my bowl of rice when we are having dinner, then that’s not good. But smoking is my fault, I was wrong first.” Although smokers did not say what about their intervention participation changed their attitude, they nonetheless reported reacting less negatively to nonsmoker household members’ urges not to smoke compared to pre-intervention.

Some nonsmokers in both moderate-intensity and brief-intervention groups reported greater assertiveness for smokefree living after attending a group session. A nonsmoker in the moderate-intensity group reported, “Before, I didn’t tell him not to smoke. But now, I would talk to him about smoking; tell him not to smoke too much, and to remind him sometimes.” One nonsmoker in the brief-intervention group stated that she became more assertive around others outside of her household:

I have changed. I asked my neighbor and my brother to quit smoking. I told them quitting smoking is beneficial for their health. It is good for their trachea and lungs and so forth.

[Facilitator:] So, you wouldn’t say these things in the past?

[Nonsmoker:] Yes, I didn’t usually say these things in the past.

Most smokers in both intervention groups reported continued difficulty being assertive when offered cigarettes, particularly at work, social gatherings, casinos, and when visiting mainland China. An exception was one smoker in the moderate-intensity intervention, who reported that after joining the intervention, he decreased his tobacco use and stopped going to gatherings where friends would encourage him to smoke. When asked whether he would lose friends, the participant responded:

No. I explained to them. I used what I learnt from this program to tell them that smoking is harmful to our bodies.”

[Facilitator:] Did they laugh at you?

[Smoker:] Yes, at first they did. But then I explained to them that smoking hurts your throat and other things, so I smoked less and gradually I quit.

Theme 4: Biochemical Feedback Was Useful But Had Short-Term Effects

One novel feature of the interventions was that each smoker and household member received a lab report of their long-term smoke exposure levels. Both smokers and nonsmokers expressed that these reports helped motivate change. One nonsmoker stated, “Letting us know about the results are important. It is because of the results that affect him…he doesn’t believe anything I say in everyday life. It is equal to when you see the doctor, and the doctor has a report for you to look at.” A smoker in the brief-intervention group similarly said, “To me, as Chinese, we have a saying that: ‘If you don’t say it, you don’t know. After you look at this, you are shocked.’ The damage is very serious. We have never done this kind of thing before.” Another smoker in the moderate-intensity group stated: “But of course your program is very helpful to us, especially the lab results indicating in different colors such as red and orange. It’s pretty scary. If I die, that’s fine, but I don’t want to burden the younger generation and my family. I feel a bit scared.” A smoker in the moderate-intensity group recommended more lab reports, saying, “Then we would quit faster.”

However, some participants expressed difficulty in understanding the lab report. One nonsmoker said, “There is a form (referring to the report) that we took home. But I do not know how to read, so I do not even look at it.” Some smokers whose reports revealed relatively low NNAL levels did not feel the lab report changed their behavior: “To me, it doesn’t make a difference, because I am at the lowest. So, I think it is not a big issue.” Many smokers and nonsmokers stated that after they received the report at the clinic, they did not look at it again:

[Nonsmoker:] We didn’t discuss much about the report. We just put them together at our home.

[Interviewer:] You did not take them out and talk about them.

[Nonsmoker:] Yes, it’s just a paper.

Others reported that initially receiving the report was shocking and motivated them to quit or reduce, but the report did not have a long-lasting effect on smokefree behaviors.

Theme 5: Project Magnets Provided Cues to Action

Most participants across all groups reported that they retained project magnets even after completing the intervention. They were provided to remind participants of the intervention assessment schedule. Many participants reported placing the magnets on their refrigerator, and seeing it daily. Several smokers reported that the magnet was a helpful cue or “alert” to refrain from smoking. One smoker stated, “It helps to reflect myself on what am I doing. I am quitting smoking.” However, smokers noted that the magnet was only a helpful reminder at home and they continued to struggle to abstain smoking in other environments. The magnet also encouraged other household members to support smokers’ cessation. For example, a moderate-intensity group nonsmoker reported: “We put this magnet on our fridge. Our daughter doesn’t understand Chinese. But there is a [crossed-out] cigarette there. She knows what it means, so she tells her dad not to smoke.”

DISCUSSION

The present study provides insights on promotion of smokefree educational interventions for Chinese American smokers and nonsmoker household members. Participants reported a preference for dyadic and group interventions facilitated by health professionals and involving smokers and nonsmoker household members. Refusal strategies for smokers and assertive communication strategies for nonsmokers encouraged behavior change. The current findings also suggest that tangible cues to action are useful features of smokefree educational interventions.

Preference for group and dyadic interventions involving smokers and nonsmokers indicate that social support is important for Chinese immigrants, which has been found in other studies.^{8, 9, 10} Current study findings suggest that not only is family involvement important, but nonsmoker household members’ participation can help them become more knowledgeable about the health harms of tobacco use and more assertive in encouraging smokers in ways that are perceived by smokers to be supportive. Such shared knowledge within families has been suggested to facilitate nonsmoker support for cessation in a study involving Chinese and Vietnamese Americans.¹⁰

Changes in attitudes and household communication were facilitated by the involvement of the health educator, who legitimized nonsmokers’ concerns about the harms of smoking and helped smokers “save face” in discussions about smoking.¹⁹ Given these cultural concerns and traditional patriarchal hierarchy,²⁰ clinicians working with Chinese and other populations where social standing is an important driver of behavior should consider having those with perceived credibility (e.g., doctors or other health professionals) deliver interventions and be sensitive to discussion topics that may produce shame or loss of face.²¹

A lab report displaying smokers’ and nonsmokers’ smoke exposure levels and a house-shaped project magnet with a no-smoking sign were provided to participants in the current study. These provided visual cues to action for participants and other household members. The feedback on smoke exposure was shocking for many participants, and supports theories such as the Health Belief Model that suggest that increasing perceived risk will motivate behavior change.¹⁵ The insights participants in the current study provided suggest that such cues are helpful, but may need to be simplified for those with less education and strengthened to cue action in other environments (e.g., work, car) where smokefree living may be challenging. Moreover, future interventions may be more effective with increased follow-up calls or visits by health professionals to improve knowledge and motivation for change.

Although all participants were provided information about in-language quitline services, few actually called to receive counseling and those who did were discouraged by the difficulty of getting through to a counselor. Rather, despite participants’ busy schedules, all preferred to have face-to-face intervention meetings, although this may reflect selection bias in terms of who could participate. Preference for in-person meetings may also reflect a culturally normative channel for building trust and receiving health information. This also suggests that to enhance utilization of quitlines, which have been shown to be effective for Asian language callers,²² expedient and culturally normative access to in-language services is crucial. Direct provider electronic referral with a quitline counselor proactively calling smokers in their preferred language is a promising strategy.

It should also be acknowledged that many participants discussed smoking reduction rather than cessation, and, at the time of the current study, nearly three-quarters of smokers were still smoking and 41% reduced from daily to non-daily use. Although smoking reduction often precedes successful cessation,²³ given that our interventions emphasized the health harms of secondhand smoke exposure, we did not encourage reduction but rather complete cessation. Future studies may examine whether encouraging reduction may be an effective short-term strategy for this population. Moreover, although our interventions improved household support for smokefree living, the environments that most encouraged smoking were workplaces, casinos, and returning to mainland China. Addressing these risky contexts and equipping individuals to protect themselves from smoke exposure is important,²⁴ particularly given that enforcement of smokefree policies continues to be challenging in many places^{25, 26} and for certain groups such as less-educated Asian immigrant women.⁷

Our study had several limitations. Although focus group format was chosen to encourage in-depth discussion among participants with shared experiences and the facilitator encouraged participation and dissenting opinions, the format may have discouraged discussion among some individuals. The sample included only immigrant Chinese American male smokers and most household members were female spouses. Those who are U.S.-born and/or of other ethnicities, or have other household member relationships, may have different perspectives. Substantive differences in perspectives among participants in the two interventions were not detected; however, it is likely that the sampling methodology limited the breadth of insights on smokefree interventions. Although this limits the generalizability of the study’s findings, it is weighed against the depth of perspectives provided.

CONCLUSIONS

This qualitative study provides perspectives on acceptable intervention strategies to promote smokefree living among Chinese American immigrant smokers and nonsmoker household members. Including nonsmokers in interventions empowered them to assert smokefree preferences and support smokers in cessation. Simple and tangible cues to action sustained motivation for behavior change.