Abstract
China has the largest number of smokers in the world; more than half of adult men smoke. Chinese immigrants smoke at lower rates than the mainstream population and other immigrant groups do. This qualitative study was to explore the influence of denormalization in Canada on male Chinese immigrant smoking after migration. Semistructured interviews were conducted with 22 male Chinese Canadian immigrants who were currently smoking or had quit smoking in the past 5 years. The study identified that, while becoming a prospective/father prompted the Chinese smokers to quit or reduce their smoking due to concern of the impacts of their smoking on the health of their young children, changes in smoking were also associated with the smoking environment. Four facilitators were identified which were related to the denomormalized smoking environment in Canada: (a) the stigma related to being a smoker in Canada, (b) conformity with Canadian smoking bans in public places, (c) the reduced social function of smoking in Canadian culture, and (d) the impact of graphic health messages on cigarette packs. Denormalization of tobacco in Canada in combination with collectivist values among Chinese smokers appeared to contribute to participants’ reducing and quitting smoking. Although findings of the study cannot be claimed as generalizable to the wider population of Chinese Canadian immigrants due to the small number of the participants, this study provides lessons for the development of tobacco control measures in China to reverse the current prosmoking social environment.
Introduction
China has the largest number of smokers in the world, with more than 50% of adult men smoking (World Health Organization Western Pacific Region, University of Waterloo, & ITC Project, 2015). The tobacco-attributed proportion is increasing in men, but low, and decreasing, in women. Although overall adult mortality rates are falling, as the adult population of China grows and the proportion of male deaths due to smoking increases, the annual number of deaths in China that are caused by tobacco will rise from about 1 million in 2010 to 2 million in 2030 and 3 million in 2050, unless there is widespread cessation (Chen et al., 2015).
China signed the Framework Convention on Tobacco Control (FCTC) in November 2003, and ratified the FCTC in January 2005. However, progress in complying with FCTC tobacco control policies has been slow. China missed the 2009 deadline to implement a national ban on smoking in public places (World Health Organization, 2010), but in late 2014, the city of Beijing passed municipal legislation to ban all indoor smoking in public buildings, including schools and offices, effective on June 1, 2015 (World Health Organization Western Pacific Region, University of Waterloo, & ITC Project, 2015). The effectiveness of the local legislation in control of indoor smoking in public places has yet to be evaluated. Without national legislation in China banning smoking in public places, exposure to secondhand smoke among nonsmokers in China is high. In China, 740 million nonsmokers—including 182 million children—are exposed to secondhand smoke at least once a day in a typical week. The most recent multinational survey on effectiveness of smoke-free policies in 22 nations including China, the International Tobacco Control Policy Evaluation Project, reported that China is unfortunately a world leader in secondhand smoke exposure among the 22 participation countries (World Health Organization Western Pacific Region, University of Waterloo, & ITC Project, 2015). Among the smokers in China, 70% reported smoking in workplaces and homes, and 82% of restaurants and 89% of bars permitted smoking (World Health Organization Western Pacific Region, University of Waterloo, & ITC Project, 2015).
System and cultural factors pose challenges for tobacco reduction in China. The central government is still deriving large tax revenues from tobacco sales, and the tobacco industry employs a large workforce (Hu, Mao, & Shi, 2010). In addition, cigarette gifting and sharing is embedded in men’s daily lives as a ritualized practice to maintain and expand social connections (Ding & Hovell, 2012; Mao, Yang, Bottorff, & Sarbit, 2014; Rich & Xiao, 2012). Within this context, smokers in China either do not want to quit smoking or experience immense barriers to quitting. A national survey reported that 75.6% of smokers had no plan to quit smoking (Jiang, Elton-Marshall, Fong, & Li, 2010). Smokers and nonsmokers considered quitting “impossible” or “impractical” because of the importance of smoking in men’s social lives (Mao, Bristow, & Robinson, 2013; Mao et al., 2014).
Contrary to smokers in China, Chinese men outside the country have been labeled “model” immigrants in reducing or stopping their smoking after migrating to a country or region with low smoking rates (Zhu, Wong, Tang, Shi, & Chen, 2007). For example, a study with Chinese immigrants in California, the United States, identified that 52.5% of Chinese smokers had quit smoking and remained abstinent for 1 year (Zhu et al., 2007). Although this quit level was comparable to the quit rate for California smokers in general (53.3%), the quit rate among Chinese immigrants was roughly seven times the quit rate in China (Zhu et al., 2007). Other studies have reported similar findings: Chinese immigrant smokers tend to reduce their smoking more than other subpopulations (Li, Kwon, Weerasinghe, Rey, & Trinh-Shevrin, 2013; Mao, Bottorff, Oliffe, Sarbit, & Kelly, 2015; Tong, Tang, Chen, & McPhee, 2011; Wyatt, Trinh-Shevrin, Islam, & Kwon, 2014). No in-depth knowledge is available on why Chinese immigrants succeed in their reduction and cessation given the prosmoking culture from which they migrate. Such knowledge is useful for the development of tobacco cessation interventions for Chinese immigrants and for the implementation of tobacco control measures in - China.
This study will address two interconnected questions: (a) How do Chinese male smokers respond to a denormalized smoking environment following immigration? (b) What prompts Chinese immigrant smokers to reduce or quit smoking? The study was conducted in Canada, where a comprehensive range of tobacco control measures has been implemented to denormalize tobacco use (Health Canada, 2015). Canada is one of the countries in the world with the lowest smoking prevalence. The Canadian national survey on smoking patterns in 2013 reported the overall current smoking prevalence is 14.6% among Canadian population aged 15 years and older, with men’s smoking (16%) a little higher than women’s (13.3%; Propel Centre for Population Health Impact, 2015).
Method
Participant Recruitment
The data for this study were obtained as part of a larger project exploring the smoking experiences of Chinese Canadian new fathers. Participants were recruited through bilingual advertisements that were distributed to Chinese organizations in the lower mainland of British Columbia, Canada, and Chinese online forums in Canada. The Chinese forums were parts of Chinese websites in Canada, covering various aspects of life. It was free to put on advertisements in the forums and the advertisements could be on the forums for months. People who were interested in the study contacted the research team by telephone or e-mail and those eligible for the study were invited to participate in the study.
Men who responded to the recruitment advertisements were screened for eligibility. Criteria for eligibility included the following: (a) self-identified as a Chinese immigrant or a Chinese Canadian, (b) currently smoking or having quit smoking in the past 5 years, (c) having lived in Canada for at least half a year; as the original project per se, participants were expecting a child or had a child younger than the age of 5 years. Twenty-two men recruited through the Chinese forums (n = 21) or through the Chinese organizations (n = 1) met study criteria and provided informed consent. Among the 22 participants, 12 came from Ontario, 8 from British Columbia, and 2 from Quebec, representing the three most populous provinces in Canada. All participants were the first-generation Chinese immigrants and they had lived in Canada for 8.7 ± 6.4 years (range = 0.5-22 years). Characteristics of the sample are reported in Table 1.
Demographics and Smoking History of the Participants (n = 22).
The study was reviewed and approved by the Behavioural Research Ethics Committee of University of British Columbia, Canada. All the participants provided informed consent and were offered a CAD$50 honorarium to acknowledge their participation in the study.
Data Collection
Semistructured interviews were conducted via telephone with all the participants except one, with whom a face-to-face interview was conducted. The participants were encouraged to compare the differences in their smoking practice between China and Canada. Questions included are as follows: How did your smoking change after you moved to Canada? How are Chinese men different from Canadians in terms of smoking practices? What helped you the most to quit smoking? What were the barriers? Follow-up questions were used to encourage participants to expand on their answers or clarify details related to their experiences. A brief questionnaire was administered to collect participant demographic information and smoking patterns.
Data Analysis
All interviews were digitally recorded, translated into English and transcribed. A bilingual research assistant with Chinese and English proficiency translated the interviews and the translations were checked by the bilingual researcher (AM). The team used a qualitative interpretive approach to data analyses (Strauss & Corbin, 1998) and developed a coding framework based on readings of the first three interviews. Three members of the research team (AM, JB, and GS) independently coded these three interviews. Definitions about the codes were established to facilitate the independent coding. For example, the code “Patterns of smoking” was defined as “Any comments about when, where, why the participant smoked, the length of smoking, and beliefs about smoking and health.” The code “Facilitators for quitting” was defined as “What men believe helps them/others quit smoking and comments about what men need to help them quit smoking and about what helps men stay smoke-free.” The three researchers reviewed and debated discordant narratives to reach consensus on the interpretation of the findings. Repeated narratives about the participants’ smoking and quitting experiences were evident and indicated that data saturation was achieved.
Once the coding framework was refined and became stable, the qualitative data management program NVivo8 was used to code and retrieve data. Data coded to each category were reviewed in detail, comparing and contrasting data from all participants to identify the facilitators and barriers related to smoking in both cultures.
Results
All the participants had at least one child younger than 5 years. The average age for the participants was 38 ± 5.0 (range = 28-46 years). The participants had lived in Canada for 8.7 ± 6.4 years (range = 0.5-22 years), indicating that they were relatively new immigrants. All the 22 participants were smoking at the time they migrated to Canada. At the time of this study, 12 of the men had quit smoking (defined as having stopped smoking for at least 1 week), while the other 10 were still smoking. All the current smokers were smoking less than they had before.
As all the participants were fathers of children younger than 5 years or were expecting a child, they claimed that becoming a father had prompted them to quit or reduce smoking because of concerns about the impact of their smoking on the health of young children (Mao et al., 2015). However, changes to their smoking were also associated with the negative attitudes of the Canadian society toward smoking. The participants were impressed by the significant difference in smoking practices between China and Canada. The participants described the general acceptance of smoking and its place in everyday life in China and contrasted this with the “antismoking” culture they encountered in Canada. It was in this context that the men’s smoking practices were challenged. Four facilitators related to tobacco denormalization prompted the participants to reduce or quit after immigration: (a) the stigma related to being a smoker in Canada, (b) conformity with Canadian smoking bans in public places, (c) the reduced social function of smoking in Canadian culture, and (d) the impact of graphic health messages on cigarette packs. The following section will detail these facilitators. The participants were numbered according to the sequence they entered the study.
The Perception of Stigma as Motivation
Due to the comprehensive smoking restrictions in Canada, the participants viewed smoking as a behavior performed by a minority of Canadians, and perceived smoking as a sign of low social economic status. A participant who had been in Canada for 8 years and smoked less than 10 cigarettes per day (CPD) said, “I notice that smokers here are usually from lower social conditions. People who have better jobs usually don’t smoke. You can see that many construction workers smoke” (#11).
The participants could sense how smoking on the street and in public attracted negative attention and that smokers often experienced social discrimination in Canada. A participant who had been in Canada for 18 months recalled that he quit smoking soon after immigrating, primarily due to the stigma he experienced related to smoking:
The people’s attitudes towards your smoking . . . I mean people don’t like our smoking. So when people passed us, we turned away, not to face them directly so that the smell didn’t spread to them. Anyway this big environment had pressure on us. (#8)
Compared with China, where access to cigarettes was easy and commonplace, for instance from street vendors, buying cigarettes in Canada usually demanded overt requests of store clerks which in turn risked judgment. A participant who continued to smoke in Canada, but at a reduced level compared with his smoking in China, described how restricted access to cigarettes exacerbated his perception of stigma:
In China you can get cigarettes even from the vendors who sell newspapers. Here you have to go to the gas stations or supermarkets and you have to ask the clerks where to get cigarettes. In China they display various cigarettes to you; here they hide the cigarettes in counters. So it is troublesome to get cigarettes in Canada. Sometimes I joke about that is a kind of discrimination. (#11)
Although participants eventually located neighborhood shops that stocked their preferred brands, the regulated access added to their perception that smoking was categorized as undesirable, and almost contraband.
Compliance With Smoking Bans in Public Places
The men also suggested that they reduced their smoking because there were very few places in Canada that allowed smoking. This was in sharp contrast to China where smoking was permitted almost anywhere. A participant who immigrated 11 years ago and eventually quit smoking 3 years ago after he initially reduced his smoking, described how it simply became too hard to continue smoking when indoor environments were all smoke-free:
I feel like the entire Canadian society is against smoking. For example, you cannot smoke inside the office buildings, schools, cars, restaurants. If you really want to smoke, you will have to go outside of the building, which is really inconvenient sometimes because it is cold outside. (#12)
Participants also noted a difference in adherence to smoke-free rules between the two countries. They pointed out that there were smoking bans in China, but people usually ignored them, while people in Canada tended to respect smoke-free rules. A participant who had been in Canada for 12 years and currently smoked two to three CPD remarked on the difference:
In China, if policemen put up a no-smoking sign, people may ignore the sign. They may take out a cigarette to smoke because of the reminder. In Canada, if the policemen put up a sign for whatever reason, people will comply. (#5)
As the Chinese participants adjusted to smoke-free public places, they often transferred these rules to their domestic spaces, creating a smoke-free home. The participants explained that because most Canadians maintained a smoke-free indoor environment, they found it easier to keep their own homes smoke-free, even when visitors who smoked came to their home. One man who still smoked stated: “Here I have some friends who smoke. When they come to my home, they don’t smoke inside. We all go outside to smoke. You don’t have to tell them to do so. It is a rule here” (#5).
The Reduced Social Function of Smoking in Canadian Culture
The participants observed and commented on how there was no equivalent practice in Canada to cigarette sharing and gifting as practiced in China. A participant who had lived in Canada for 1 year, and reduced to three to four CPD, reflected on the practice of gifting cigarettes. “In China we receive and give cigarettes. Here we don’t give out cigarettes. This is quite different” (#10). Although the participants perceived Canadian social relationships to be lacking in depth, they welcomed the chance to dispense with gifting cigarettes, because it helped them take control of their smoking. A participant who had been in Canada for 3 years and quit smoking 4 months ago described how freedom from gifting cigarettes facilitated his quit:
We Chinese have a habit which is not very good. When we have dinner together we share cigarettes and fill each other’s cups with alcohol. You know Chinese people usually don’t decline the offer. Your refusal will make them very uncomfortable. They will feel losing face. Here in Canada if you don’t want to smoke you don’t have to, because people don’t offer you cigarettes. (#2)
The participants observed how cigarette smoking in Canada was simply a recreational activity and not embedded in men’s job performance. One ex-smoker explained:
In China smokers may say how important their smoking is to the success of their work and refuse to quit smoking. Here in Canada smoking doesn’t bring benefits to your success in your work. If you offer your business partner cigarettes or treat them to dinner it is bribery. (#8)
Without cigarette sharing and gifting, the social capital of smoking was viewed as lost in Canada. This diminished social function of smoking translated to reduced motivation to smoke and fewer barriers to quitting.
Participants interpreted the vastly different costs of Chinese and Canadian cigarettes as reflecting the acceptability of smoking in the two countries. The diversity in the cost of Chinese cigarettes had implications for gifting practices. Participants described being compelled to purchase and gift expensive cigarette brands in China:
In China the cheaper cigarette brands can be one or two RMB but the more expensive ones can be over 1,000 RMB. The brand you offer to other people represents your face or social status. I was a business man in China, so I always had to buy cigarettes that were 100 or 1,000 RMB not 10. (#8)
Another participant, who was also new (1 year) to Canada and a current smoker, made similar observations about how the pricing of cigarettes in Canada implied their lack of social significance:
As far as I know, the most expensive brand in Canada is around $12 and the cheapest is $7-8.There is no big difference in the prices of cigarettes in Canada. Smoking is more of a personal habit in Canada. So it doesn’t matter how expensive the cigarettes that you are using. (#10)
It is interesting that participants readily compared their cultural knowledge about the social function of smoking and the corresponding wide price range of cigarettes in China with the narrow price range of cigarettes in Canada, concluding that in the host culture, smoking fulfilled a different function, simply meeting individual and personal needs.
The Impact of Graphic Health Messages on Cigarette Packages
The World Health Organization FCTC requires that health warnings on cigarette packs describe the specific harms of tobacco (World Health Organization, 2014), but the warnings on Chinese cigarette packs merely state: “Smoking harms your health” and “Quitting smoking early helps reduce the risk.” These text-only warnings blend into the color and design of the cigarette package. The participants noticed that unlike cigarette packaging in China, which are beautifully designed, Canadian cigarette packages deliver health information with graphic warnings. Some participants acknowledged they felt less desire to smoke after seeing the Canadian antitobacco messages. A participant who quit smoking 3 years ago said: “They are awful pictures, like lungs and teeth, on the packing of the cigarettes in Canada. I felt uncomfortable with the pictures. I didn’t want to smoke after I saw the pictures” (#12).
One participant, who had quit smoking, compared the graphic warnings on Canadian packs with a slide show lecture on the health effects of smoking he had attended in high school, “I was shocked by what I saw on that show. I still remember what I saw in that show after so many years. I think pictures and video are a better way of health education than texts only” (#13).
These commentaries are interesting in light of tobacco research with Canadian-born research participants who often speak derisively about cigarette pack health messages, claiming they have no effect (Haines-Saah, Bell, & Dennis, 2015). But, clearly, for these Chinese smokers exposure to provocative antismoking images had a profound impact.
Discussion
The findings of this study provide additional support for tobacco control measures aimed at denormalizing tobacco use (Li et al., 2013; Liao et al., 2010; Tong et al., 2011; Zhu et al., 2007). While the Canadian environment denormalizing tobacco use appears to have been an important factor influencing tobacco reduction and cessation among these Chinese immigrant men, it is important to also consider the impact of Canadian and Chinese concepts of self. The Chinese self-concept is shaped by collectivism, and the Canadian by individualism, a difference supported in the literature (Bottorff et al., 2010; Lee, 2002; Mao, 2013; Mao et al., 2013). Chinese men smoke mainly to conform to the rules of social functions, while Canadians smoke with the conviction it is their individual choice and personal right. In the current study, the pressure to conform to Canadian nonsmoking values and save “face” prompted collectivist cooperation, and this shift in tobacco norms was made easier in the absence of cigarette gifting. Although collectivism explains the participants’ willingness to conform to antitobacco rules, participants spoke with awareness about individualism and how it influences behavior in Canada, and recognized mainstream antismoking values as linked to personal choice. This leads to the notion that perhaps, in a globalized world, tobacco control and health promotion in China could successfully borrow from concepts of individualism and freedom of choice to overcome the weight of the collectivist prosmoking culture.
The influence of the antismoking environment in Canada points to the urgent need for China to follow the example of Beijing and implement comprehensive bans on smoking throughout the country. According to the World Health Organization, there are national draft regulations in process, which suggest that the response of Beijing’s 20 million citizens to the 2015 citywide smoking ban, will be critical to China’s tobacco-free future (World Health Organization Western Pacific Region, University of Waterloo, & ITC Project, 2015). It is possible that as the prosmoking culture is eroded in China, a more benign situation may quickly emerge, due to the tendency for Chinese men to behave in accordance with the wider social environment. In addition, participants in the current study supported smoking bans in Canada, which suggests smokers in China may not oppose tobacco control policies, but rather welcome the change.
The findings from the current study also suggest some missing strategies in FCTC, regarding China. Numerous studies have provided evidence for the effectiveness of increasing taxes on tobacco products to promote smoking cessation (Ayubi et al., 2017; Hu et al., 2010; World Health Organization, 2014). Often overlooked is the need to decrease the wide range of cigarette brand prices in China. As participants in this study and the findings of others have pointed out, highly priced premier brands are closely related to social status in China, and as such become ideal items for gifts (Ding & Hovell, 2012; Mao et al., 2014; Rich & Xiao, 2012). Taxation of cigarettes should diminish the price hierarchy, which may eliminate the currency of specific cigarettes as gifts. The fact that participants were impressed by the graphic warnings on packages suggests that this may be an important area for further research to inform redesigning the current cigarette packages in China. In addition, policies restricting the availability and sale of cigarettes in Canada also appeared to influence the immigrant men’s smoking practices, and points to the potential value of similar restrictions in China.
Due to the small number of the participants in this study, the findings cannot be claimed as generalizable to the wider population of Chinese Canadian immigrants. For example, longer term immigrants may have different experiences of smoking than new immigrants, because they are affected by acculturation and smoking norms that change over time (Burgess et al., 2014; Gorman, Lariscy, & Kaushik, 2014; Mao et al., 2015; Smith, Ramsay, & Mazure, 2014). Inversely, new immigrants might be an ideal group to explore changed smoking behaviors due to their heightened sensitivity to the antismoking cultures in Canada.
In conclusion, the current study identified that Chinese immigrant male smokers were highly responsive to a denormalized smoking environment. The sharp change in their smoking behaviours can be explained by the Chinese value of collectivism, and the desire to conform to “new” cultural norms. This study provided valuable knowledge for tobacco control in China, because it revealed the systematic failure of tobacco control in China from a unique perspective. While there are challenges facing China in tobacco control, the findings support those of others whose data also indicate that a promising future in reducing smoking rates with the introduction of tobacco control policies (Yang, Jiang, Oliffe, Feng, & Zheng, 2015). This study adds to the contention that if China is serious about implementing FCTC measures, the current prosmoking social environment can be reversed.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research study was made possible by the Canadian Institutes of Health Research (Grant #62R43745) and a postdoctoral fellowship award from the Psychosocial Oncology Research Training program.