"It's Not a Life or Death Thing": A Grounded Theory Study of Smoking Decisions among Chinese Americans

Smoking results in a high mortality rate for Chinese Americans. Little is known, however, about the decisions members of this group make that lead to these unhealthy behaviors. Examining smoking decisions could help us understand these choices as well as develop effective prevention strategies. This grounded theory study was conducted to understand Chinese Americans' smoking decisions. Fifty-four individual interviews and three focus groups were conducted with Chinese Americans of different smoking statuses. The findings describe five smoking decisions including the trajectory of these behaviors. Optimistic bias is identified as one of the main reasons that regular smokers decide not to quit. Some Chinese Americans decide to smoke in order to protect themselves from secondhand smoke because of the perception that secondhand smoke is more dangerous than active smoking. Finally, many Chinese Americans change their smoking behaviors after immigration, with their social environment after immigration playing a key role. Keywords: Smoking, Decision-Making, Chinese Americans, Grounded Theory, Optimistic Bias, Immigration Cigarette smoking is a significant global health issue that has been considered a priority for the world health community (WHO, 2008). Cigarette smoking is the leading cause of preventable death resulting in over 5 million deaths each year worldwide (WHO, 2008) including 480,000 deaths in the U.S. alone (U.S. Department of Health and Human Services, 2014). Tobacco increases mortality from cancer, cardiovascular and heart diseases (Gandini et al., 2008; He et al., 2008), however, Chinese Americans continue to smoke despite reductions in smoking among American populations (U.S. Department of Health and Human Services, 2014; Gomez et al., 2013; McCracken et al., 2007). This study explores the smoking decision-making processes of Chinese Americans who continue to risk severe health problems for themselves and others around them to maintain their smoking behaviors. Understanding smoking decisions could help us better understand these choices as well as develop effective prevention and treatment strategies (Chang, Song, & Lee, 2008). Previous research identified a variety of factors that influence Chinese Americans' smoking behavior including low education level (Yu, Chen, Kim, & Abdulrahim, 2002), low language proficiency (Fu, Ma, Tu, Siu, & Metlay, 2003), lack of adequate knowledge about smoking consequences (Hu et al., 2006) and early warning signs and symptoms of cancer (Yu et al., 2002), positive social smoking norms (Tu, Walsh, Tseng, & Thompson, 2000), perceived benefits of smoking (FitzGerald, Poureslami, & Shum, 2015), acculturation (Sussman & Truong, 2010), and depression (Tsoh, Lam, Delucchi, & Hall, 2003). These factors provide a context in which Chinese Americans make smoking decisions. However, to date, little is known about the decision process, itself. We know, for example, that lack of knowledge about smoking harm is one of the main reasons that Chinese Americans smoke (Hu et al., 2006). However, we do not know if Chinese Americans use inaccurate information or just lack basic information in making smoking decisions. In other words, how these identified factors (e.g., lack of knowledge) play out in Chinese Americans' smoking decisions remain unknown. The aim of the study is to describe Chinese Americans' smoking decision processes and identify factors that influence these decisions. Literature Review Smoking Disparities and Chinese Americans The past 50 years have witnessed aggressive tobacco control programs in the U.S. that resulted in great changes of the social acceptability of smoking (U.S. Department of Health and Human Services, 2014) and, ultimately, in decreased smoking prevalence (CDC, 2011). However, this success has not been uniformly shared by all segments of the population. Smoking remains a problem particularly among Asian Americans (Maxwell, Crespi, Alano, Sudan, & Bastani, 2012; Ma, Tan, Fang, Toubbeh, & Shive, 2005), with its prevalence exceeding 50% in some Asian communities (Averbach, Lam, Lam, Sharfstein, Cohen, & Koh, 2002). …