The following is a translation of a World Journal article in response to a smoking cessation campaign by the Charles B. Wang Community Health Center. The original article was published February 28, 2016 and can be read here.
Lu Yin Xiu, World Journal
According to The Lancet’s new release, a research study shows that by 2030, there will be 2 million people who die from smoking in China. That is double the number of deaths in 2010. By 2050, there will be 3 million deaths. Due to the increase of new immigrants from China, the smoking rate is increasing in the Chinese community. In New York City, one in every four Asian males age 25 – 44 years old smokes. This is the highest of all ethnic groups. Funded by the CDC, the Asian Smokers’ Quitline in California has serviced the nation for over 23 years. Recently, they have taken the lead along with many healthcare organizations in New York to promote smoking cessation. The increase of smoking cessation staff in all partner agencies brings a new force to health. The Federation of Chinese American & Chinese Canadian Medical Societies (FCMS), a coalition of over 10 agencies across the nation and physician networks, have joined to promote the first “Chinatown Smoke-Free Day.”
Smoking Is Not Heroic, Former Police Officer Extends Assistance
Ken Ho has worked for the smoking cessation program at Asian Americans for Equality (AAFE) for over two years, and has encountered about 600 people interested in quitting. Sharing his experience as a police officer in Hong Kong, he says when police did not smoke, it was seen as unmanly at the time. Movies also depict people smoking in the office. Ho smoked one pack a day for over six years. He decided to quit smoking when he failed the physical test when applying for a government job. He noticed shortness of breath when taking the physical test. In addition, a friend died from lung cancer and his girlfriend pressured him to quit smoking. Doctors also advised him to quit. He thinks quitting smoking requires determination, but knowledge is also important. Before training to work for the smoking cessation program, he did not know one cigarette has over seven thousand chemicals. Many people think that they won’t affect anyone if they smoke outside. Secondhand smoke is also harmful to others as well as thirdhand smoke, a toxin that can come from a smoker’s clothes. It is harmful to children when you pick them up right after smoking.
Ho’s work station is close to the front desk in the Chinatown site. Usually, many elderly come to seek help with translation, which creates opportunity for conversation. They all say they are very old and that they’ve been smoking for a few decades and don’t need to quit. If it’s their time to go (die), it’s time. They are also retired and not busy, so smoking becomes a routine. When they are not smoking, they are not sure what to do with their hands. He usually becomes friendly with the elderly, chatting with them about their grandchildren, before talking to them about smoking cessation. Within six months, one elder chatted with Ken six or seven times and eventually considered quitting.
Long work hours and stress are the main reasons why new immigrants smoke. For some, it’s peer pressure. Ho says smokers sometimes call the hotline because their wives ask them to. If wives inquire on behalf of the smoker, he always asks if they know why their husbands smoke. If it’s due to stress, then he recommends the couple talk it out to resolve the problem. Quitting smoking is easier when there is family support. The next step is to manage cravings and decrease dependency. He reminds people that quitting smoking takes time and to not argue when they see their partner still smoking shortly after deciding to quit. Some people get their patches from the pharmacy and often are not successful in quitting due to lack of counseling and family support. One myth of quitting is that patches and medicine alone will successfully help you quit after several uses.
Typically, AAFE callers need to fill out a survey and will receive two weeks of supplies, like patches, gum, etc. If they decide to quit, they will be referred to a more specialized quitline. A hotline specialist will contact the client and provide smoking cessation supplies for up to six months. After a few weeks, a hotline specialist will follow up with the client. Some smokers are in the U.S by themselves and need someone to talk to. Ho always asks them to relax; he is not a navigator, but a friend. When smokers know the difference between his position and a doctor’s, it’s easier for them to open up. He often shares his experience of immigrating to the U.S. Some smokers admit to still smoking while using the patch. He recommends that they use the patch and avoid smoking.
Set a Goal and Be Persistent
Lucas Luo was a doctor in China and came to the U.S four years ago. He started at Charles B. Wang Community Health Center as the smoking cessation counselor last September as part of a new project at the Health Center. He came from Hunan when he was 30 years old and did not receive any training about how cigarettes affect one’s health. After being involved with related research, he gained a lot of knowledge and believes that Chinese give cigarettes and alcohol as gifts due to a lack of health awareness. He feels a sense of accomplishment when he helps people quit smoking, which aligns with his reason for becoming a doctor.
Since September, Luo has encountered about 90 patients; around 20 patients have successfully quit smoking, their age ranging from 20-70, but mostly from 30-50 years old. In the past, smoking cessation was promoted on the street where people usually pay no mind. During a clinical visit, if a patient is a smoker, staff will refer the patient to Luo. He provides counseling for those who want to quit. For those who do not want to quit, he provides education on how harmful cigarettes are, hoping that they will smoke less. Sometimes the doctor will prescribe nicotine patches, but the patient will not fill it at the pharmacy, so Luo tracks and encourages them. Currently, the Health Center’s smoking cessation services focuses on patients and hopes to develop a quit smoking hotline in the future as a community resource. In terms of quitting, he thinks it mainly depends on determination, especially for their child’s health. Some people see others smoke and fail since they can’t overcome the urge or don’t have a set goal. Others see smoking as a way to take a break. He suggests avoiding these situations. The advantage of being in the U.S. is that it is acceptable to refuse a cigarette when a friend offers one. You can tell them that you are quitting smoking for your health or for your children.
The initial interview with the smoker is very effective. Luo usually asks, “Why do you smoke? How does it make you feel?” Many share that smoking makes them more alert or relaxed. He also asks smokers to list all the situations where they most want to smoke and addresses the top three ones. For example, have energy drinks to be more alert, drink water or chat with someone to distract the urge, or use gum/patches for nicotine replacement therapy. The first two weeks are the most challenging period. He usually calls patients during the first week and they may inform him of side effects, like dry mouth. Some tell him about skin rashes as a result of placing the patches on the same spot all the time. If side effects become more severe, they need to schedule a follow-up visit or take oral medications. After two more weeks, he follows up again and checks if the patient wants to continue using medication. The smoking cessation project supplies one month of free nicotine patches, and patients need to return for a follow-up visit. Most come back for the free patches if they work. For uninsured patients, he helps them apply for a three-month supply of free patches.
Luo shares that people can generally last 24 hours without a cigarette. After the first attempt to quit or being cigarette-free for three to five days, they can decrease smoking frequency. When smokers receive free patches, some want to try it immediately, but being around smokers makes it much more difficult. Avoid trying to quit by finishing all your cigarettes at home or waiting until you close a (business) deal. It also makes it more difficult to quit when you smoke after using up the patches. He also finds that many attempt to quit, but since they did not use the medication correctly, they smoke even more, giving up on the attempt. There are some who feel that one patch is not strong enough and use two at a time, which can create addiction. It takes time for the patch to have an effect and maintain a steady, low level of nicotine in the body so that it relieves some withdrawal symptoms. This is effective in most cases. But after waking in the morning or having meals, when the body may need a higher level of nicotine, the gum may be better to rapidly relieve symptoms.
Quitting smoking is done in stages. Three months are usually considered one treatment stage, and six months of treatment in a year. The adverse effects of smoking are highly recognized so that most insurance companies will cover costs. During the second week of cessation, if withdrawal symptoms persist, medication dosage can be increased, and symptoms are usually relieved within a month. By three months, most symptoms will be gone.
According to data provided by the Cancer Institute at San Diego University, the success rate for Asians quitting smoking is 6% and 15% for those who received counseling. Caroline Chen, smoking cessation project manager at the Institute, states that the California smoking hotline was established in 1992 by Professor Chu and is operated by the school. The following year it became the Asian Smokers’ Quitline (ASQ), which provides counseling in Mandarin, Cantonese, Korean, and Vietnamese. They also study Asian smokers’ behaviors, thus attracting more Asian groups to join smoking cessation efforts. In 2012, ASQ became a national hotline funded by the CDC.
Many people know her as Mrs. Yip, a counselor at ASQ for 14 years. She is from Hong Kong and her father smoked for a long time. She even jokes that she smelled cigarettes as a fetus. Her father lost two-thirds of his stomach due to illness. When he was 67, he decided to quit. Ten years later, her mother, who is a non-smoker, got diagnosed with lung cancer and passed away six months later. Ten months following her mother’s death, her father also died due to lung cancer. Since her father was fragile, they did not even tell him that her mother had lung cancer. She feels that her mission is to promote smoking cessation. She does not want this kind of tragedy to happen to other families. She also shares that many international students smoke at San Diego since their family is overseas. Some are also afraid that they can’t find a spouse, so they call the hotline for help quitting. Others call the hotline because customers dislike the smell of cigarettes. They don’t want their income to be affected by their smoking. Some mothers smoke after their children go to sleep, and since quitting, feel better because they are not controlled by nicotine.
Besides the nicotine addiction, there is the hand-to-mouth habit. Smokers crave smoking when they see someone having a cigarette. They accept the cigarette when it is offered. If they don’t smoke after waking up, they can’t function; if they don’t smoke before bedtime, they can’t sleep. They are dependent and need assistance to quit. Many call and ask about e-cigarettes, thinking that it can replace the real one, but Yip says that the hand-to-mouth motion is the same and they still inhale nicotine. Usually people use it for a while and go back to regular cigarettes. There are not many who can successfully quit smoking using an e-cigarette.
When quitting smoking, Yip suggests not being with other smokers during breaks. Don’t place cigarettes where smokers can access them. She also suggests that smokers find ways to deal with cravings. For example, drink water, eat fruit, exercise, etc. She recommends not planning too far ahead and taking small steps. Try not to smoke for one day and see how it feels. Try another day if you succeed. Then try not to smoke for one week, and another week, and so on. She shares that many people need multiple attempts to quit. Those who successfully quit the first time usually have a reason to quit. It may be their or their children’s health. Many argue as a result of smoking, which makes them feel bad all the time. She reminds family members to encourage the smoker, not nag them. Some say that quitting is so painful that the more you think about it, the more you want to smoke. If that is the case, she suggests taking a break outside, finding some new hobbies, or helping with house chores. When you successfully quit, you send your children a positive message that you are trustworthy and keep your word.
Yip had a case where the wife dialed the hotline and when connected, handed the phone over to her husband, telling him someone was looking for him. When the husband realized that the call was for quitting smoking, he was angry. Some people want to get patches to help their family member quit. This is not effective if the smoker does not want to quit. Many people see their coworkers use the patches to quit, so they also want to get patches and try to quit. But some say that they work so hard and don’t find reason to quit. They offer cigarettes to challenge those attempting to quit. There are various scenarios; some are not successful even though they have tried to quit for a year or two. She reminds people not to use cigarettes and give up all their hard work thus far. They can eat fruit, chat with someone, or sleep earlier to deal with the craving.
Smokers need counseling during the initial stage of quitting. During the first two or three weeks, the hotline provides five counseling sessions. The first session is to create a file for the caller, and it’s free for the uninsured. For those with insurance that don’t cover costs, they have to pay for their own medication. The following session, the hotline will ask about the caller’s smoking history, develop a quit plan, and set a quit date. Some say they will quit smoking as a birthday gift for their loved ones; others need more time to get ready, like getting snacks. Some people will not smoke when they decide to quit. But since they are not ready, they don’t know how to deal with cravings when they arise. Using patches and smoking at the same time doubles the amount of nicotine intake. Yip says the patches are to relieve cravings and help smokers use this period to learn how to deal with the hand-to-mouth habit. Otherwise, when the patches run out, people will go back to smoking. Some don’t like the nicotine smell and don’t use nicotine gum, and need a doctor to prescribe medication as a replacement. Nicotine affects sleep. Nicotine replacement therapy is usually not used at night. Some think that when they use a patch while sleeping, they won’t have the urge to smoke. In the end, they can’t sleep, need to smoke the next day to be alert, and think the patch is not effective.
Many new immigrants work at restaurants when they first arrive, so you can imagine that in a small town, during long work hours, cigarettes may be their only “friend” that they bring from “home.” They believe it is their best “friend” as well. Yip says that so far, callers are mainly from the East or West coasts. Other states may have less access to this smoking cessation information. The hotline operates from Monday to Friday, 7am to 9pm PST, which is 12am EST, so people can call after work.
New Year’s Resolution: Quit Smoking Successfully
Mr. Han, 31 years old, came from Southern Islands over 10 years ago. He started to smoke when he was in junior high school. Initially, he smoked when hanging out with a group of friends. In high school, he smoked one pack every two days. When he first came to the U.S., he felt very stressed and smoked more. During breaks while working at a restaurant, his peers also smoked. His hobbies include singing and drinking, a reason for why he smoked more. Because of the recent ban on indoors smoking and the higher price of cigarettes, he felt that smoking is no longer acceptable.
In the last two or three years, Han’s throat started to feel uncomfortable and his health began to decline. He considered quitting. When he was alone, he smoked less, one pack a week. But when with friends, it was very difficult to avoid smoking. He tried using an e-cigarette, but it did not feel the same and tasted different. Three months ago, he saw a flyer promoting smoking cessation. He wanted to try quitting again. So he called AAFE and got free patches. He started to use the patch every day and decreased cigarette use and also made a plan to quit. He called Ken Ho at AAFE to chat twice a week for about 20 minutes each session. Ho shared his experience of being a cop in Hong Kong. They built camaraderie. Ho sometimes treated him to lunch, and Han felt that if he gave up, he would break the bond.
Han craved for a smoke at nighttime when he started to quit. Besides using the patch, he also watched TV and movies and chatted on the phone to distract himself. Every day, he applies the patch after showering and removes it before the next shower. One pack has 20 patches and a new pack will arrive from ASQ after 20 days. After that, he doesn’t need to use the nicotine patch anymore. If he doesn’t go out with friends, he doesn’t need to carry any cigarettes.
Before he planned to quit, Han thought quitting required seeing the doctor regularly and taking medicine. He was also afraid that he wouldn’t be able to do it. But after trying and having support, he does not feel quitting is difficult. The greatest challenge is not being able to smoke when he is annoyed. The biggest reward is the better health he felt after quitting for a few weeks; his throat also got better. Overall, he feels great. He wants to stay smoke-free, so he also started to exercise (running). The next step is to promote smoking cessation among his friends and setting a New Year’s resolution to quit.
Community Concerns About the High Smoking Rate
Regina Lee, Chief Development Officer of Charles B. Wang Community Health Center, says that China is the world’s largest cigarette manufacturing country. Cigarettes are cheap and people’s knowledge of smoking’s harmful effects is limited. Giving cigarettes as a gift is part of male social etiquette. Cigarettes also provide important revenue so anti-smoking efforts by officials are weak. The situation is reflected in the overseas’ Chinese community. As a result of New York City Department of Health efforts, such as smoking bans in parks and public housing and increased cigarette taxes, the general smoking rate in New York has decreased year by year, to about 14% most recently. Among Asian men, however, the rate is 21%. Asian men ages 25 – 44 have the highest rate (26%), and women’s smoking rate is about 5%. This is a major problem. The smoking rate of American youth has been low recently, but smoking is considered trendy. Statistics show that American-born Asian women have a higher smoking rate than foreign-born Asian women, which is the opposite case for Asian males. This may be related to the greater acceptance of women smokers in American culture. Many women didn’t dare to smoke in China, but have found relief in the U.S.
In a physician-led quit smoking campaign in the Chinese community, the withdrawal rate was more than 50% among 200 participants. The majority had no time to revisit the clinic. As a result, the campaign used counselors with more flexibility to counsel face-to-face or by phone. In the past, when patients registered and identified as smokers, they received educational materials. Sometimes the doctors and nurses were too busy to implement the program. The program became empowered by the hiring of full-time Mandarin speaking smoking cessation counselors to provide one-on-one phone or in-person counseling. Providers don’t always have the power to convince their patients to receive counseling.
Lee says that smoking cessation programs in New York lack Chinese materials. Although New York State provides a Chinese hotline, the service is via third party interpretation, which is inconvenient. Direct Chinese quit smoking hotlines are only found in California. Some people think that quitting smoking takes only a few weeks to a month, but the study found that it actually needs three to six months to end nicotine addiction and two years for heroin. If smokers have 10 or more cigarettes per day, they need to use nicotine patches and gum. The study also found that it takes 6 to 7 attempts to quit successfully, and each attempt is a step closer to success.
Rachelle Ocampo, who leads community education, says that many inquiring about quitting express concerns of inhaling secondhand smoke in cultural associations every day. A quit smoking poster from many years ago shows a grandfather teaching his grandson to write calligraphy with one hand, while his other hand holds a cigarette. People invest a lot in their second generation’s education, but fail their health at the same time. She passes by parks in Chinatown every day. Although there are many no smoking signs and children playing in the park, many people still smoke there. As such, it is important to change the community’s tolerance for smoking. This will take time to achieve.
Electronic cigarettes are another worry for the Chinese community. Young people think e-cigarettes are cool because they can create large amounts of vapor, and they want to be part of the trend. Parents should be aware that youth believe e-cigarettes are harmless. They have different flavors, such as fruit, mint, and chocolate. Even though e-cigarettes don’t contain nicotine, they usually have unknown chemicals and don’t have labels. They are actually as dangerous as regular cigarettes.
Recently, AAFE has worked with New York University to hire Chinese-speaking tobacco cessation navigators and provide free nicotine patches. Flora Ferng, AAFE’s Director of Programs, says free resources have not been consistent in the past, which has affected smokers’ efforts and desire to quit. AAFE is a social service agency where many people seek assistance for family or employees with smoking problems when they go for food stamp applications, job vacancies, and business seminars. The smoking cessation program is similar to a social work service. Many smokers depend on cigarettes due to stress. Once social workers help them find a job or apply for social welfare, their dependence on cigarettes lessens. The quit smoking program is handled by experienced counselors.
Ferng says many Chinese restaurants still allow smoking. Smuggled cigarettes can be ordered via phone for a cheap price and includes home delivery. There seems to be no reason for the Chinese to quit smoking. If quitting is brought up in a community setting, many smokers feel embarrassed and will find an excuse to leave by taking a phone call or going to the restroom. She visits construction sites and restaurants and uses the opportunity to introduce the smoking cessation program while providing information on home purchases, health care, and other social services. Many immigrants have a tough life and do not think of smoking as a big problem. At the same time, they also know secondhand smoke harms their family and pets, and will call the quit smoking hotline. Some smokers said they want to quit but have no time to see a doctor. Many want to refer their family members, hoping their husbands or sons will quit. Others consider quitting. About one-third of smokers are willing to set a quit date, use nicotine patches, or cut down on smoking. Smoking cessation needs reason and good timing. Perhaps smokers will take action when they get physical examinations in the future.
Perry Pong, MD, Chief Medical Officer of Charles B. Wang Community Health Center, explains that American anti-smoking efforts are more intense than other countries and New York has the strictest policies with the highest cigarette tax. However, in the Chinese immigrant community, smoking seems like a normal practice as a result of stress. Many say they are always tired from work and need some relief. Nicotine has mood-boosting effects that make people feel more energetic to work and earn money. Nicotine is a highly addictive substance and medicine can treat the addiction. However, people with psychological addictions need encouragement and reminders from their companions. Because men often provide a family’s main source of income, it is hard to admit illness from smoking. Many suffer some other illnesses but are not willing to visit a doctor. When male family members get sick, it can harm the whole family’s financial stability.
Many say they don’t smoke at home. Data shows that children who grow up in a smoking family have a higher asthma rate. Many smokers say they don’t want to see their children smoke; school and society provides a lot of anti-smoking education. However, smokers’ own habits only show their children that smoking is a normal practice. The idea is simple: when parents like reading, their children will learn from their example and like reading too; children like to watch TV if their parents enjoy watching TV too.
The Chinese community is similar to the U.S. general society in that those with less education receive less information about smoking. Tracking this group makes sense, as they may live their lives more day-to-day and rely on smoking to get through each day. Dr. Pong said smoking is a cumulative habit; it is easier to quit when smokers are still young. It is difficult to change habits, especially at the beginning and for heavy smokers who smoke one pack a day. In the first month or two, patients may suffer from twitching, depression, irritability, headaches, and other symptoms due to nicotine withdrawal. Therefore, smokers need to use patches, gum, and other medicine to overcome the symptoms. Changing habits takes time. At this stage, smokers also need someone to support them and remind them to not give up.
The second part of nicotine addiction is psychological dependence. If someone regularly smoked to deal with pressure in the past, they will need a new strategy. After a month or two, they can establish new habits. Electronic cigarettes are still contested in the medical field. Many chemical ingredients are not clear and lack legal oversight. Some believe that e-cigarettes are better than regular ones because they do not burn anything. It will take several years to gather scientific evidence on whether they cause disease, but Dr. Pong has never heard of any studies that say e-cigarettes can help people quit.
Smokers might not think about quitting in their twenties, but many diseases gradually emerge as they age. Once they quit smoking, the chances of getting these illnesses will decline immediately. The best way to avoid any type of cancer and cardiovascular disease is to quit smoking. Chinese doctors’ joint advocacy for smoking cessation is sending a strong message to the community. Blood work may not diagnose heart disease or cancer, so a CT scan is recommended to discover those diseases in the early stage. Do not just get a checkup, though. Quitting smoking is the best way to avoid these illnesses. Most insurance including those for low incomes cover smoking cessation medications. The Chinese community needs to have more Chinese-speaking counselors to lower healthcare costs. Dr. Pong also hopes insurance will cover future counseling costs instead of relying on government funds.
“Chinatown Smoke-Free Day” Sounds the Alarm
Smoking can cause the following cancers: leukemia, bladder, cervical, colon, esophageal, tracheal, oral, nasal, throat, stomach, kidney, pancreatic, ureter and other diseases such as heart disease and stroke. The Chinese American Medical Society, Chinese Medical Association of Southern California, Chinese American Physicians Society, East Bay, Chinese Canadian Medical Society, Chinese Community Health Care Association, Chinese Hospital Medical Staff, Philippine Chinese American Medical Association, Chinese American Independent Practice Association, and the Eastern Chinese American Physicians Independent Practice Association together hope to promote “Chinatown Smoke-Free Day” this year.
Executive Director of the Federation of Chinese American & Chinese Canadian Medical Societies, cardiologist Dr. Warren Chin, says that unlike having high blood pressure or high cholesterol, quitting smoking is the easiest and most effective way to eliminate risk factors for many diseases. In a smoking community, non-smokers may also develop lung cancer and should get screened. Because screenings used x-rays in the past, cancer was always discovered only in the last stage. Former smokers and non-smokers who have lived with a smoker are now encouraged to receive a low-dose CT scan, which can detect cancer in the early stage. In addition, there are new surgical techniques that do not remove lungs. In the past, lung cancer had less than a 10% one-year survival rate, compared to a 60% five-year survival rate today.
The clinical study in the Chinese community also found that many young immigrants have heart disease, and many of them are restaurant workers. Interestingly, some patients deny smoking but physicians can smell smoke on them. Many say they came from a cultural association, where people play mahjong and smoke. Although New York City has banned indoors smoking in public areas and patients are aware of the harmful effects of smoking, they are not aware of the dangers of secondhand smoke. Dr. Chin suggests promoting smoking cessation among community associations. “Chinatown Smoke-Free Day” will work with several organizations participating across major cities. Similar to World Hepatitis Day, the campaign aims to raise awareness of the harms of smoking. Sometimes smokers and their families just need an extra push to quit.
As a doctor, Dr. Chin advises patients to quit smoking. Many agree, but do not take action. He has found that pressure from a spouse may be more effective because it comes from the family. When a grandson says, “Grandpa, please don’t smoke—you want to see me grow up,” it is a very powerful statement. There is a higher success rate when medications, follow-up counseling, and community resources are used by doctors. “Chinatown Smoke-Free Day” encourages Chinese physicians to participate in smoking cessation more proactively. Dr. Chin believes families joining together for “Chinatown Smoke-Free Day” will empower smokers to put out their cigarettes. This will eventually change the smoking culture.