1 Smoking among Vietnamese American men in relation to traditional health beliefs Presenter: Nadine L. Chan, MPH University of Washington & Fred Hutchinson Cancer Research Center National Conference on Tobacco or Health December 11, 2003

2 Acknowledgements Vietnamese Community Coalition and Interviewers Vietnamese Community Coalition and Interviewers Vicky Taylor MD, MPH Vicky Taylor MD, MPH Yutaka Yasui PhD Yutaka Yasui PhD Carey Jackson MD MPH Carey Jackson MD MPH Beti Thompson PhD Beti Thompson PhD NCI Grant #CA NCI Grant #CA Biobehavioral Cancer Prevention and Control Training Program: NCI Grant #R25 CA92408 Biobehavioral Cancer Prevention and Control Training Program: NCI Grant #R25 CA92408

3 Agenda Background on Background on –smoking among Southeast Asians –traditional health practices Vietnamese Health Study in Seattle, WA Vietnamese Health Study in Seattle, WA Methods Methods Findings Findings Implications Implications

4 Background: Tobacco Use Tobacco use is single most preventable cause of death and illness in US CDC, 1998 Tobacco use is single most preventable cause of death and illness in US CDC, 1998 –One in five deaths –87% of lung cancer deaths Lung cancer is the leading cause of cancer death among all Americans Lung cancer is the leading cause of cancer death among all Americans Lung cancer rates in Southeast Asians are 18% higher than general population Chen and Hawks, 1995 Lung cancer rates in Southeast Asians are 18% higher than general population Chen and Hawks, 1995

5 Smoking Prevalence Prevalence Prevalence –34% to 43% among Southeast Asian men vs. –27% in white men Centers for Disease Control and Prevention, 2000 Tobacco use different by sex Tobacco use different by sex –Much higher in API men than in women –More than 70% of newer male immigrants from Laos or Cambodia smoke

6 Prevalence in King County, WA King County Ethnicity and Health Survey, 1998

7 Why?

8 Challenges for Tobacco Control More than 50% of tobacco companies exports are sent to Asian countries More than 50% of tobacco companies exports are sent to Asian countries Higher density of billboards and store displays in Asian neighborhoods (e.g. San Diego) Elder et al, 1993 Higher density of billboards and store displays in Asian neighborhoods (e.g. San Diego) Elder et al, 1993 –6.4/Asian store –4.6/Latino store –3.7/African American store –lowest in white neighborhoods

9 Challenges for Tobacco Control Lack of knowledge of health effects of tobacco use NAWHO, 1998 Lack of knowledge of health effects of tobacco use NAWHO, 1998 –1 in 5 Vietnamese did not know smoking causes heart disease, bronchitis, emphysema, COPD, and mouth cancer –27% (1 in 4) Vietnamese adults did not know smoking can cause cancer

10 Challenges for Tobacco Control “Little is known about levels of tobacco control awareness or attitudes and beliefs about tobacco in Asian American populations.” National Asian Women’s Health Organization, 1998

11 Hold that thought…

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

13 Vietnamese Health Project 2002 Purpose Purpose –Identify cancer preventive behaviors specific to Vietnamese American communities Team Team –Harborview Medical Center –Refugee Immigrant Health Clinic –Vietnamese Community Coalition –Fred Hutchinson Cancer Research Center

14 Project’s Theoretical Framework PRECEDE conceptual framework used for potential determinants of smoking PRECEDE conceptual framework used for potential determinants of smoking –Predisposing factors (traditional beliefs, knowledge, attitudes) –Enabling (availability and access to health services) –Reinforcing (family, peer, medical support) Green et al 91

15 Methods: Sampling Cross-sectional survey design Cross-sectional survey design Addresses from 7 South Seattle zip codes Addresses from 7 South Seattle zip codes List of Vietnamese last names to identify Vietnamese households from phone book List of Vietnamese last names to identify Vietnamese households from phone book Identified 1,639 households Identified 1,639 households Randomly sampled n=900 households Randomly sampled n=900 households –Interviewed one man and one woman (18-64 yrs) in each household

16 Methods: Recruitment Publicized surveys through posters in community Publicized surveys through posters in community Mailed introductory letters to each household Mailed introductory letters to each household Conducted interviews in respondents’ homes using bilingual, bicultural interviewers Conducted interviews in respondents’ homes using bilingual, bicultural interviewers Tokens of appreciation Tokens of appreciation –Original artwork depicting scenes from Vietnam –Summary of social and health resources

17 Methods: Instrument and Analysis Instrument Instrument –Sociodemographic characteristics (19- items) –Smoking (37-items) –Traditional health beliefs (11 items) Analysis Analysis –Descriptive statistics using STATA 7.0

18 Results: Demographics Cooperation Rate: 82% Characteristic N = 509 Age (mean yrs,SD) 44 (12) Education (mean yrs, SD) 13 (3) Education level (%) < 12 yrs < 12 yrs 12 yrs 12 yrs > 12 yrs > 12 yrs Born in Vietnam (%) 99 Proportion life spent in US (%) 30 Age at immigration (yrs, SD) 32 (13)

19 Results: Demographics Characteristic % (N = 509) Marital status Currently married Currently married Previously married Previously married Never married Never married80417 English fluency (well/fluent) 48 Vietnamese fluency 97 Religion Buddhist and other Asian Buddhist and other Asian Catholic or Protestant Catholic or Protestant None None53398

20 Results: Demographics Characteristic % (N = 509) Employment status Employed Employed Unemployed Unemployed7723 Housing Public Public Rented Rented Owned Owned Have health insurance Yes Yes No No8515

21 Results: Prevalence Variable % (N = 509) Smoking status Former Former Current Current Never Never Asked if smoked in last routine check-up 72 Have friends who smoke 94

22 Results: Knowledge Variable % Correct (N = 509) Smoking can cause lung cancer 97 Second-hand smoke can cause lower respiratory tract infections in children 96 Is addictive 95 Second-hand smoke can cause lung cancer in non-smokers 87 Causes heart disease 83 Second-hand smoke can cause heart disease in non-smokers 76 Causes stroke 70

23 Results: Attitudes Variable % Agree (N = 509) Smoking not allowed anywhere inside home 93 Smoking is widely accepted among men in Vietnamese community 82 Appropriate for men to smoke with friends 30 Appropriate for women to smoke with friends 2

24 Results: Attitudes Variable % Agree (N = 509) Gifts of tobacco acceptable in Vietnamese community 16 Impolite to refuse cigarette by host 13 Smoking makes men appear more sophisticated and confident 12 Smoking makes women appear more sophisticated and confident 4

25 Results: Traditional Health Beliefs and Correlations with Current Smokers Variable % Agree (N = 509) SmkCorr Illness -can be prevented by taking herbs -can be prevented by taking herbs -can be prevented by maintaining a positive attitude -can be prevented by maintaining a positive attitude is a matter of karma or fate -is a matter of karma or fate -is caused by imbalance of cold/heat -is caused by imbalance of cold/heat Course of illness changed by faith 61- Some diseases caused by wind illnesses 52+

26 Results: Traditional Health Beliefs and Correlations with Current Smokers Variable % Agree (N = 509) SmkCorr Some American medicines too strong 26- Western medicine is as good or more effective to treat A. root cause of illness B. symptoms Should visit a Dr regularly even without problems 93- Coining is best treatment for some illnesses 50+

27 Traditional Health Beliefs Independently Associated with Current Smoking OR 95%(CI) Some diseases are caused by wind illnesses 1.6 (1.10, 2.33) Illness is caused by imbalance cold/heat 1.7 (1.09, 2.69)

28 Traditional Health Belief Summary Msrs vs Current Smoking Status Independent variable OR 95% CI Strong/weak traditional health beliefs , 1.82 Traditional health belief score , 1.23

29 Summary High prevalence of smoking among Vietnamese American men High prevalence of smoking among Vietnamese American men Strong traditional beliefs held about health Strong traditional beliefs held about health Current smokers independently associated with belief that Current smokers independently associated with belief that –illness caused by wind –illness caused by imbalance of heat/cold

30 Implications Little change in prevalence of smoking in this community since 1995 Little change in prevalence of smoking in this community since 1995 Smokers may attribute poor health especially to wind or cold/heat imbalance instead Smokers may attribute poor health especially to wind or cold/heat imbalance instead Smokers may believe that illness is fated, but that Western medicine will cure Smokers may believe that illness is fated, but that Western medicine will cure Possibly identify risk in community using a summary score for traditional health beliefs Possibly identify risk in community using a summary score for traditional health beliefs

31 Limitations Generalizeability to other regions or to neighborhoods with smaller proportions of Vietnamese residents Generalizeability to other regions or to neighborhoods with smaller proportions of Vietnamese residents Acquiescence bias Acquiescence bias Direction of causality undetermined because of cross-sectional nature of analysis Direction of causality undetermined because of cross-sectional nature of analysis

32 Strengths of Study Community-based sampling method Community-based sampling method Use of theoretical model to guide project Use of theoretical model to guide project First known study to look in depth at the associations between traditional health beliefs and smoking status in a high risk population First known study to look in depth at the associations between traditional health beliefs and smoking status in a high risk population

33 Questions?

34 Summary Scale for Traditional Health Beliefs