KNOWLEDGE, ATTITUDES AND PRACTICES REGARDING SMOKING AMONG IMMIGRANT SMOKERS IN FINLAND
Harsha Shetty Master’s Thesis Public Health School of Medicine
Faculty of Health Sciences University of Eastern Finland April 2018
2 UNIVERSITY OF EASTERN FINLAND, Faculty of Health Sciences
Public health
SHETTY, HARSHA G. M. K.: Knowledge, attitudes and practices regarding smoking among immigrant smokers in Finland
Master’s thesis: 95 pages, 1 attachment (10 pages).
Instructor: Dr. Sohaib Khan, MBBS, MPH, PhD.
April 2018
Key words: Smoking, knowledge, attitude, practice, immigrants, Finland
KNOWLEDGE, ATTITUDES AND PRACTICES REGARDING SMOKING AMONG IMMIGRANT SMOKERS IN FINLAND
Immense scientific interest has been generated for the past few decades on the topic of smoking among migrants, and this could be attributed to acculturation. Though there are voluminous research done on this topic in the west, studies done among immigrants in Finland is sparse.
Hence, the present study aimed to assess and evaluate the knowledge, attitudes and practices (KAP) concerning smoking among immigrants in Finland. Smoking is the pre-eminent preventable cause of death and disability, with the possibility of minimization through imposition of taxation on tobacco products and introduction of unattractive unbranded packaging. The blueprint designed by the Government of Finland aims towards a Smoke-Free Finland, by helping both the existing smokers quit and prevent further rise in number of newer smokers. Increase in pricing and fabrication of less alluring packaging to reduce tobacco usage by consumers, were the key takeaways of this blueprint. The KAP data derived from studies as this could be used to revamp the governmental strategies and policies.
The study was conducted in the Helsinki Capital Region. Helsinki Capital Region was chosen as the study setting due to higher number of immigrants and diversity in socio-economic status among the diversely stratified subject population, in this region as compared to the rest of Finland. Hence, the choice of this study setting helped to quantify the impact of diversity in socio-economic status on the disparity in smoking practices among the immigrants. The study subjects were volunteers that were former smokers or those who smoked currently, residing within the study setting. Cross sectional study design employing qualitative structured in-depth interview utilizing a self- reporting questionnaire and phenomenographic approach was deployed in this study. Various socio-demographic factors that affected the KAP of the study subjects regarding smoking were also included during the analysis of the collected study data.
Results illustrated distinctly that acculturation did not have much influence on smokers under study. Internet and Social media were the best media to spread anti-smoking campaigns. Peer pressure, socio-economic status influenced smoking prevalence. Smoking rates surpassed for single males and females compared to their wedded counterparts.
3
Acknowledgement
I would like to express my heartfelt gratitude and deepest appreciation to Dr. Sohaib Khan, my principal research supervisor for his continuous support and guidance through all stages of this study. His relentless efforts, painstaking involvement starting from the inception of this research idea to planning of the study, evaluation and correction of the entire thesis has been tremendous.
Thank you for your encouragement and valuable insights. You shall always be remembered with gratitude.
I also want to express my gratitude to Dr. Ari Haaranen, PhD. for his acceptance to be my principal examiner for this study. In the same breath, I would like to thank Dr. Sohaib Khan for his willingness to be my second examiner. I would also like to thank all the academic and administrative staff of the Institute of Public Health and Clinical Nutrition, University of Eastern Finland (UEF) at Kuopio, especially Dr. Jussi Kauhanen, the Director, for helping create such an intellectual and friendly environment for learning.
I would also wish to express my sincere appreciation and gratitude to all the participants of this study for their willingness and the quality time which they committed towards the interviews.
Without them sharing their information and inputs, this study would not have taken the contour it has now. My earnest thanks to everyone who, directly and indirectly supported this study.
Above all, I acknowledge with gratitude the support of my beloved family who stood by me throughout and for their enduring encouragement, without whom all my academic endeavors would mean nothing.
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List of Abbreviations
AAPIs – Asian-Americans or Pacific Islanders BC – Before Christ
BRFSS – Behavioral Risk Factor Surveillance System CAD – Coronary Artery Disease
CAMs – Cell Adhesion Molecules CBT – Cognitive Behavioral Therapy
CDC – Centers for Disease Control and Prevention CI – Confidence Interval
COPD – Coronary Obstructive Pulmonary Disorder CTS – California Tobacco Survey
CVD – Cardio-Vascular Disease DALY – Disability Adjusted Life-Years
DDT – Di-chloro Di-phenyl Tri-chloroethane
EPA – United States Environmental Protection Agency ETS – Environmental Tobacco Smoke
EU – European Union
FCTC – Framework Convention on Tobacco Control
HEW – United States Department of Health, Education and Welfare HHS – United States Department of Health and Human Services IHD – Ischemic Heart Disease
i.e – that is
KAP – Knowledge, Attitude and Practice LDL – Low Density Lipoprotein
LOS – Length of Stay
MSAH – Ministry of Social Affairs and Health, Finland
NCCDPHP – National Center for Chronic Disease Prevention and Health Promotion NCI – National Cancer Institute
NGO – Non-Governmental Organization NHIS – National Health Interview Survey
NO – Nitric Oxide
5 NRT – Nicotine Replacement Therapy
PHA – Public Health Agency of Canada RCT – Randomized Controlled Trial SES – Socio-Economic Status SHS – Second hand smoke
THL – National Institute for Health and Welfare, Finland
UK – United Kingdom
US/ USA – United States of America
USPHS – United States Public Health Service WHO – World Health Organization
6 Contents
1. INTRODUCTION ... 8 2. LITERATURE REVIEW ... 10
2.1 Smoking 10
2.1.1 Impact on Health 10
2.1.2 Prevalence around the globe 11
2.1.3 Prevalence in Europe 12
2.1.4 Prevalence and patterns in Finland 13
2.1.5 Anti-smoking initiatives - European region 14
2.1.6 Anti-smoking initiatives - Finland 15
2.1.7 Impact of education on Smoking 17
2.2 Immigration 17
2.2.1 History of immigration 17
2.2.2 Cultural identity and Immigration 18
2.2.3 Prevalence of smoking among immigrants around the world 19
2.2.4 Immigrants in Finland 20
2.2.5 Acculturation 20
2.2.6 Smoking knowledge, attitudes and practices among immigrants 23
2.2.7 Smoking cessation interventions among immigrants 29
3. AIMS OF THE STUDY ... 31 4. MATERIALS AND METHODS ... 32
4.1 Study design 32
4.2 Study setting 32
4.3 Study subjects 32
4.4 Methodology 32
4.4.1 Data collection tool 33
4.4.2 Data collection process 34
4.4.3 Data analysis 34
4.5 Ethical consideration 34
5. RESULTS ... 36
5.1 Study Participants 36
5.2 Socio-demographic factors 37
5.2.1 Age 37
7
5.2.2 Sex 38
5.2.3 Marital Status 39
5.2.4 Nationality 40
5.2.5 Location of Birth and Length of Stay 41
5.2.6 Length of Stay 42
5.2.7 Occupation 43
5.2.8 Socio-Economic Status 44
5.3 Knowledge 47
5.4 Attitudes 54
5.5 Practices 57
6. DISCUSSION ... 66
6.1 Discussion of the findings 66
6.1.1 Influence of Socio-demographic characteristics 66
6.1.2 Knowledge, attitudes and practices 69
6.1.3 Effects of smoking 72
6.1.4 Passive smoking 74
6.2 Strengths and limitations of the study 76
7. CONCLUSION AND IMPLICATIONS ... 79 8. REFERENCES ... 80 9. APPENDICES ... 96 9.1 Questionnaire Attachment 1 (1/10) 96
8 1. INTRODUCTION
The year 2014 marked the fiftieth anniversary of the release of report on ill-effects of tobacco smoking on health in the US Surgeon General’s report. The conclusions of the report made way to additional research on consequences of continued tobacco use and potential approaches to reduce tobacco consumption. A wide spectrum of potent interventions was available including raising costs and ban on advertisements, promotion, sales to minors, smoking in public places. The adoption of the Framework Convention on Tobacco Control (FCTC) in 2003 and its subsequent authorization by 177 countries reflected growing global efforts to control tobacco.
Inspite of these tremendous efforts, tobacco continues to adversely influence global health patterns, leading to 5.7 million deaths, 6.9% of years of life lost and 5.5% of disability adjusted life-years (DALYs) in the year 2010. It is established that usage of tobacco in all forms including cigarette smoking, as one of the most leading, avertible inducer of morbidity and mortality in the world (HEW 1979, HHS 1983, HHS 1989, WHO 2008, Haddad et al. 2012, CDC 2018). Mortality across the globe due to tobacco is predicted to accelerate from four million deaths in the year 1998 to cross 10 million in 2030 with 50% of these deaths to take its toll between 35–69 years age group with a total average loss of 20–25 years of life (WHO 1999). Nearly four-fifths of these deaths transpire in low- and middle-income countries (Boopathirajan & Muthunarayanan 2017).
Annually in the United States of America (USA or US) alone, tobacco usage and cigarette smoking results in greater than 0.43 million deaths (HHS 2010, HHS 2000). Group A carcinogen, Environmental tobacco smoke (ETS) is accountable for almost 3,000 lung cancer-induced deaths annually among non-smokers in the USA (EPA 1992).
Considering tobacco as a risk factor to health, monitoring the distribution and usage of tobacco is vital for identifying high-risk areas for action on implementing anti-tobacco initiatives (Ng et al.
2014). While recognizing smoking as the prominent preventable cause of death and disability, the Government of Finland has designed a blueprint towards a Smoke-Free Finland, formulated to both help existing smokers quit and preventing rise in number of new smokers. The key features of the blue print include imposition of taxation on tobacco products and introduction of unattractive unbranded packaging. The idea behind was that by both elevating the price and making the packaging less alluring to consumers, will reduce the use of tobacco. Other aspects of
9 the roadmap involved helping those who want to relinquish smoking and creation of more smoke- free habitats, in residential properties, vehicles in which children travel and locales that they frequently visit such as beaches, parks and play areas. The goal of the roadmap was to achieve a substantially smoke-free society by the year 2030. The amended Finnish Tobacco Act of 2010 aimed at prevention of usage of tobacco products, promote cessation and hence, protect the population against exposure to tobacco smoke. The Act aimed at ending the use of tobacco products consisting of carcinogenous and addictive compounds.
Tobacco smoking is the practice of combustion of tobacco and inhaling the smoke .The practice was believed to have commenced between 5000–3000 BC. Smoking is the most common method of consuming tobacco. The raw product is generally mixed with additives and then burnt, the resulting smoke then inhaled and the active substances absorbed through the lungs. Additives like potassium or other nitrates increase combustion. Many substances in cigarette smoke triggers chemical reactions in the nerve endings, which heightens the heart rate, alertness and reaction time (Mishra & Mishra 2013).
Many smokers get into the habit of smoking in adolescence or early adulthood. During early stages, perceived pleasure of smoking and overcoming peer pressure offsets the distasteful symptoms of initial use like nausea and coughing. After few years, the avoidance of withdrawal symptoms and negative reinforcement becomes the key motivations to continue.
Smoking of cigarettes is a health-risk demeanor with substantial cultural dimensions and is a predominant causative factor of diseases in the USA. Much of the current research on smoking has concentrated on diversity in the usage of tobacco, smoking commencement or initiation, smoking cessation, responses to cigarette price rises and the effects of workplace smoking constraints within and among racial and ethnic minority groups (Baluja et al. 2003).
Smoking amidst migrants has been a subject matter of burgeoning scientific curiosity in the past decades, this could be attributed to acculturation. Acculturation is the mechanism of psychological and cultural adaptation that occurs when two cultures converge, as it transpires in migration.
Though there are voluminous research done on this topic in the west, studies done among immigrants in Finland is sparse. Hence, the present study aimed to gauge and evaluate the knowledge, attitudes and practices pertaining to smoking among immigrants in Finland.
10 2. LITERATURE REVIEW
“Smoking is a custom loathsome to the eye, hateful to the nose, harmful to the brain, dangerous to the lungs, and in the black, stinking fume there of nearest resembling the horrible stygian smoke of the pit that is bottomless” - King James I of Great Britain, 1604.
Smoking is the act of inhaling smoke, produced by the combustion of an element, through the mouth, usually of tobacco in a cigarette, cigar or pipe. Cigarette smoke encompasses above 4,000 chemicals, including 43 carcinogenic compounds and 400 other toxins. Ingredients include nicotine, tar, carbon monoxide, formaldehyde, ammonia, hydrogen cyanide, arsenic and DDT (dichloro diphenyl trichloroethane). Nicotine is highly addictive. Smoking results in respiratory and cardiac diseases which eventually leads to the death of the smoker. Chemical dependency in smoking is caused due to nicotine. Nicotine Replacement Therapy (NRT) is an effective method of getting de-addicted from smoking (Rabinoff et al. 2007).
2.1 Smoking
The history of smoking predates to as early as 4000 BC in the Americas and 5000 BC in the Babylonian civilization. Tobacco intoxication then was purely for spiritual reasons. Cannabis, hookah and opium were the most common form of smoking. The adverse effects of cigarette usage came to light in the year 1920. Formal statistical evidence of a lung cancer–tobacco link was established in 1929 after a study published by Fritz Lickint. It was a frenchman named Jean Nicot after whom the word ‘Nicotine’ is derived, who introduced tobacco to France from Spain in the year 1560, later spreading to England. Tobacco was used as a beverage like tea or coffee.
Tobacco was a form of intoxicant originally used as a form of medicine.
2.1.1 Impact on Health
Usage of tobacco and second hand smoke (SHS) or passive smoking are acknowledged to be the most prominent avertible risk elements for chronic respiratory diseases such as asthma, chronic obstructive pulmonary disease (COPD), lung and oral carcinomas and cardiovascular diseases (CVD) such as ischemic heart disease (IHD) and hypertension (Beardall & Edwards 1995, Baliuan et al. 2007, The Lung Association 2008, Prasad 2009, Ray et al. 2009).
11 Smoking has an impact on multiple chronic illnesses. Yet, the outcomes are much more drastic for those with respiratory diseases (PHA 2007). Cessation of smoking would have the greatest impact on minimizing the issues and exacerbations associated with respiratory ailments, predominantly COPD (WHO 2008). Additionally, the health impact of usage of tobacco is not only on smokers but stretch to non-smokers through exposure to environmental tobacco smoke (ETS) or SHS or passive smoke, causing fatalities of almost 62,000 in adult non-smokers from coronary heart disease (CHD) and 3,000 from lung carcinomas. Among infants, exposure to SHS is noted to be a hazardous determinant for low birth weight, chronic middle ear infections, respiratory illnesses such as asthma, bronchitis, pneumonia and also plays a pivotal role in sudden infant deaths (NCI 1999, HHS 2010).
2.1.2 Prevalence around the globe
Smoking prevalence around the world revealed that the estimated age-standardized prevalence of daily tobacco smoking for men declined from 41.2% to 31.1%, an average yearly rate of decline of 0.9% and for women declined from 10.6% to 6.2% or 1.7% per year between 1980 and 2012.
There were three phases of global progress in reducing the age-standardized prevalence of smokers for both men and women. There was a modest progress between 1980 and 1996 (mean annualized rate of decline, 0.6%) followed by a decade of more accelerated global progress (mean annualized rate of decline, 1.7%) then a deceleration in reductions from 2006 to 2012 (mean annualized rate of decline, 0.9%), with supposedly increase since 2010 for men. This plunge in the global trend was partly due to increase in the number of smokers since 2006 in several large countries including Russia, China, Indonesia and Bangladesh. Since 1980, the global rate of slump in women was persistently higher than in men. While estimated age-standardized prevalence declined, the growth in population older than 15 years resulted in a continuous acceleration in the number of men and women who smoke daily, increasing from 721 million in the year 1980 to 967 million in the year 2012. Between 1980 and 2012, the number of cigarettes smoked worldwide increased from 4.96 trillion to 6.25 trillion. There was no discernible trend in the global average number of cigarettes smoked per smoker per day, remaining around 18. In men, prevalence increased rapidly in the 15- to 19-year and 20- to 24-year age groups in both developed and developing countries. The highest prevalence rates were seen between the ages of 30 to 34 years in developed countries and ages of
12 45 to 49 years in developing countries. Between the ages of 35 to 39 years, prevalence was routinely higher in developing countries.
Among women, the age pattern of prevalence differed markedly between developed and developing countries. In developed countries, the age pattern of prevalence in women was very similar to men, but at a much lower level. In developing countries, there was a unique age pattern.
Prevalence among women was very low and increased with age. The highest prevalence rates (>20%) in women occurred between the ages 20 and 49 years in developed countries, while rates higher than 40% were observed among men between the ages of 40 and 54 years in developing countries. The largest annualized rates of change worldwide between 1980 and 2012 were attained among 15- to 19-year-olds: 1.8% for men and 2.8% for women (Ng et al. 2014).
2.1.3 Prevalence in Europe
A survey done in Europe revealed that the highest smoking prevalence stated in national surveys were from Bulgaria (45.2%), Greece (40%) and Slovakia (38%); and the highest Eurobarometer estimates for Greece (42%), Bulgaria (36%), and Latvia and Hungary (36%). The lowest estimates in national surveys were for Portugal (19.7%), UK (22%) and Italy (22.7%); and in Eurobarometer for Portugal (24%), Slovenia (23%) and Sweden (18%). On an average, the Eurobarometer prevalence estimates were higher than those from national surveys by 0.37 percentage points, but with a 95% range (on 26 degrees of freedom) from 10.49 to +11.23 percentage points. At the extremes of the range of absolute differences the national estimate for Slovakia was 13 percentage points higher than the Eurobarometer figure, while the UK national estimate was 10 percentage points lower. There was positive and significant correlation between Eurobarometer and national smoking prevalence estimates (p<0.01). Mean daily and occasional smoking prevalence in the 20 countries for which daily and occasional smoking prevalence figures were available were 25.1%
and 5.6%, respectively and for the same countries in the Eurobarometer study, mean regular and occasional smoking prevalence estimates were 25.5% and 4.2%. Comparison of the national survey estimates with figures from the 2008 Eurobarometer survey, which used similar methods to the 2006 study, reveals mean figures that were 1.5 percentage points higher in Eurobarometer, with a 95% range from 6.7 to +9.6 percentage points (Bogdanovica et al. 2011).
13 2.1.4 Prevalence and patterns in Finland
Among general population, Finland has the lowest smoking figures in Europe. According to the reports for 2014, the differences in smoking prevalence are considerable among different socioeconomic groups, both in men and women. For men between 0–9 years of education (low), 21% were daily smokers. The corresponding percentage for men between 10–12 years of education (middle) was 22% and for men with 13 or more years of education (high) was 13%.
2.1.4.1 Smoking among adolescents
Majority of the Finnish adolescents are non-smokers and experimenting with tobacco has also raised to later age. The typical age range of the first-time smoking of tobacco is from 13 to 16 years. In accordance with the latest Adolescent Health and Lifestyle Survey (2015), 12% of boys and girls aged 14–18 years smoked daily. The smoking prevalence among youth has approximately halved in the recent decades.
The socioeconomic status (SES) prevalence among adults for smoking seems to be already observable in adolescence as well. Data from the School Health Promotion Study showed the prevalence of daily smoking among students in general upper secondary schools is five times less than smoking prevalence of students in vocational upper secondary schools (6% vs. 30%). In the secondary school, the prevalence of daily smoking is 93%. There has been a decrease in overall prevalence of smoking in different school types since the year 2011 (Helldan 2012, Härkänen et al. 2014).
2.1.4.2 Smoking among Adults
Since 1980’s smoking in Finland has reduced according to 2014 Finnish population survey health behaviour and health among the Finnish adult population study wherein smoking rates in men was 17% and 14% in women. Yet, the number of occasional or daily smokers among the 15–84 year- old population stands approximately about 0.875 million that makes up 15.8% of the total population. In 2013, daily smoking men was 8% as compared to 7% in women wherein the trend of daily smoking denotes decrease among men but slight inflation among women from the year 2009. Prevalence of daily smoking is more among men than women and is also observed among pension-age population (Tobacco Statistics 2016b).
14 2.1.4.3 Comparison to neighboring countries
Results of a comparative study undertaken in Finland, Estonia and Lithuania to study the prevalence of patterns of smoking in this region depicted that both active and passive smoking was more in these two Baltic countries than Finland. Smoking was more among the youth, less educated and women, with no difference between urban and rural areas. The anti-tobacco campaigns had to be targeted towards the men, younger women and less educated.
2.1.5 Anti-smoking initiatives - European region
In the European Union (EU), smoking rates prevailed among an average of 29% of the adult population, with 700,000 premature deaths each year. Smokers do wish to relinquish smoking but find it tough to give up nicotine. Though there is a reduction in smoking, the pace is slow.
Cessation of smoking results in marked reduction of probability of development of cardio- pulmonary diseases. Lengthier the duration of quitting of smoking (cessation), elevated is the health risk reduction (Okuyemi et al. 2006, Robles et al. 2008).
Cutback in smoking prevalence is important to bring about a reduction in the current non- communicable disease burden. The current anti-smoking measures have not been effective in bringing about a drastic reduction. Taxation, health warnings on tobacco, ban on tobacco advertising and sponsorship, smoking in public places, campaigning about ill-effects of tobacco, electronic cigarettes are the procedures widely used (Wilson et al. 2012).
The health warnings on tobacco packets have brought only 2% reduction in smoking prevalence over 5 years, which transcribes into 0.5% decline in prevalence during that frame of time.
Historical gains elsewhere have also been modest: graphic warning labels in Canada in the year 2000 are estimated to have helped reduce smoking prevalence by between 2.87 and 4.86% over a 9-year period, i.e. between 0.32 and 0.54 annually. The contribution of conventional treatment interventions to reducing population prevalence of smoking appears inconsequential: in experimental studies involving randomized controlled trials, nicotine replacement therapy (NRT) has evidence of improving the chances of quitting tobacco, but NRT confers no favor over stopping without any aid. This means that countries face continued smoking-related morbidity and mortality over the decades (Goniewicz et al. 2014).
15 Evidence showed that increasing taxes and price increase on tobacco alone diminished smoking prevalence amid youths and adults, while smoking bans aptly impact general population behaviour through reducing smoking opportunities and de-normalizing smoking. Advertising increases positive user image of tobacco, increases inquisitiveness about tobacco among new users and impacts beliefs and perceptions of tobacco use (DiFranza et al. 2006, Brown & Moodie 2009).
Banning tobacco restricts such experimentation by the youth. Cigarette health warning labels create awareness about health risks and increase knowledge of hazards of smoking and motivates one to quit. Health warnings have been cited as a motivating factor among tobacco quitters.
Warning labels are cost-effective for governments as compared to mass media campaigns. Indirect proof describes the impact of warning messages on knowledge, thought process, cognitive processing and the association between these intermediate outcomes with attempts and intentions to quit or cessation behavior. Electronic cigarettes have also been widely promoted (Hammond et al. 2006, Wilson et al. 2012).
2.1.6 Anti-smoking initiatives - Finland 2.1.6.1 Laws to curb smoking
Tobacco Act (693/1976) was introduced in Finland in 1976 and brought into effect a year later to deploy measures with sole intention to scale down the usage of tobacco products (THL 2016b). In 1995, smoking became prohibited at workplaces and public places. As per the reform of the Tobacco Act of June 2006, smoking in pubs and restaurants is banned. The sale of tobacco to children below 18 years of age is prohibited in Finland. Prohibition of tobacco and strong alcohol advertising is prohibited too. Many Finnish landlords urge on non-smoking rental agreements.
2.1.6.2 Policies
Legislative actions, health promotion and national monitoring systems, policies aimed at downsizing tobacco consumption through public awareness campaigns, bans in advertising and raise in taxation are multiple initiatives that have influenced the downward trend in the smoking prevalence including those such as ban on sale of tobacco products to children and to prevent sale of illegal tobacco products. Traditional collaboration between the health authorities and non- governmental organizations (NGOs) and intensive but aggressive health promotion are the key elements in the successful tobacco policy.
16 Figure 11: Measures and areas of Finland’s health-oriented tobacco policy (Heloma et al. 2012)
As per the blueprint, the main direct impact activities carried out to reduce tobacco usage are promoting smoke-free environments, imparting information and free-way communication supporting non-smoking and all out support for cessation of smoking habit. Tobacco product targeted initiatives include maintaining the high pricing of tobacco products; sales, promotions and
Prevention of the health hazards of tobacco
Health care Health promotion Price policy Legislation:
Tobacco Act
Research and development
Withdrawal services
Current Care guidelines
Education of professionals
Organizations
Mass media
Schools
Act on the Excise Duty on
Tobacco
Increases in the excise duty on
tobacco
Population’s protection againsttobacco
smoke Public areas
Public transport
vehicles
Definitions of tobacco smoke as a carcinogenic
substance
Occupational safety and
health legislation
Educational institutes
Workplaces
Restaurants
Monitoring
Health hazards
Nicotine addiction and
smoking habits
Product control
Composition
Fire safety Marketing restrictions
Total ban on advertisements
Warnings on cigarette packs
Sales restrictions
Age limit
Vending machines
Sales permits
Display of products and trademarks
Withdrawal practices
17 marketing (advertising) prohibition and hence, limit the availability of tobacco products, content regulation (nicotine, tar, carbon monoxide levels) and stringent usage of health warnings on product packaging (MSAH 2014). Framework Convention on Tobacco Control (FCTC) was adopted by the World Health Assembly in May 2003 with provisions for members to have comprehensive legislation to constrain the tobacco epidemic.
In the forefront to promote smoke-free environment and tobacco control measures in Finland is the Ministry of Social Affairs and Health (MSAH) as it is liable for the execution of the Tobacco Act, supervised by the National Supervisory Authority for Welfare and Health (MSAH 2014).
In the month of May 2016 Tobacco Act was renewed, as EU dictated newer legislative measures on all its member state’s tobacco legislation through Tobacco Products Directive. Hence, the goal of the Tobacco Act was renewed in line with the Government of Finland’s intent and blueprint to cease usage of tobacco and nicotine products; and thus making Finland, tobacco and nicotine free by the year 2030 (THL 2016a, Finlex 2018b).
2.1.7 Impact of education on Smoking
It was reported that in women, daily smoking was 21% in the low education group, 19% in the middle education group and proportion being lowest as 11% in the high education group. For women, the educational differences in smoking have increased between the year 2000 and 2011.
Smoking increased among low educated while it decreased only among high educated. However, in men, educational differences did not increase during 2000–2011 (Huisman & Kunst 2005).
2.2 Immigration
Immigration is the international movement of people into a destination country of which they are neither natives nor possess citizenship, in order to settle or reside, especially as permanent residents or citizens, or to take up employment as a migrant worker or temporarily as a foreign worker.
2.2.1 History of immigration
The history of evolution describes animal migration, migration of birds and pre-human migration.
The article named pre-modern human migration explains the first migration in human history from
18 Africa into the Middle-East, Asia, Australia, Europe, Russia and the Americas. The word migrant or immigrant is derived from Latin word “migrare” which means wanderer. The word “emigrant”
denotes the country which they leave. Sociology uses the term migration for immigration (Bhugra
& Becker 2005).
2.2.2 Cultural identity and Immigration
Culture can be explained as a characteristic that are shared and bind people together into a well- defined community. Identity is the entirety of one’s perception of self or how we, as individuals view ourselves as unique from others (Shah et al. 2014). According to studies done in the past, racial, cultural and ethnic identities form part of one’s identity and the identity will transform with development at a personal as well as at a social level along with migration and acculturation (Bhugra & Becker 2005).
Acculturation could be a voluntary or a forced process, where culturally divergent groups of people come into contact, resulting in the assimilation of cultural values, customs, beliefs and language by a minority group within a majority community. During the acculturation process, both the immigrant and host cultures may change. Transformation in attitudes, family values, generational status and social affiliations can ensue; however, typically one culture dominates the other (Bhugra 2004).
Cultural alteration in identity can at times be stressful resulting in problems with self-esteem and psychological health. Contact between the immigrant and host community may lead to integration, assimilation, rejection or deculturation. Rejection is withdrawal of the individual from his majority group. This may lead to segregation or apartheid in utmost cases. Deculturation is a loss of cultural identity, alienation and acculturative stress, leading to ethnocide. Cultural shock leads to conflict in post-migration stresses, which may further lead to cultural confusion, alienation, isolation and depression. Attitudes of the host societies, racism, unemployment, inability to meet expectations, financial challenges, legal issues, poor housing facilities and a general lack of growth opportunities within the host society, that can lead to psychological problems in susceptible individuals (Bhugra 2004).
19 2.2.3 Prevalence of smoking among immigrants around the world
A study was done to assess smoking prevalence among migrants in the US compared to the US- born and the population in countries of origin. Study results revealed that the prevalence of smoking among migrants was diminished for both men (14.2%) and women (4.1%). It was lower for both the US-born group men: 21.4% and women: 18.1% and the natives for men: 39.4% and women: 11.0%. The gender difference among migrants was lesser than in the countries of origin.
Age at time of entry to US was not a determining factor. The risk of smoking for highly-educated migrants was almost similar to their US counterparts. The smoking prevalence among migrants is consistently lower in comparison to the levels both in the country of origin and the US. This could be because of segmented assimilation or because of healthy migrant effect (Bosdriesz et al. 2013).
Studies done on immigrant Asian-Americans revealed that recent smokers had strong association to migration in comparison with previous smokers who were light smokers.
A study focused on effects of sex discrepancy in smoking behavior among Asian and Latino immigrants to the United States, displayed the effects of acculturation. A band of 3,249 Asian and Latino immigrant adults aged 18 years and older were included in the study. The study outcome was that the smoking prevalence amidst Asian immigrant men was more than 4 times that of Asian immigrant women (30.4% and 7.1%, respectively). Concurrently, the smoking prevalence among Latino immigrant men was more than twice that of women (29.5% and 12.6%, respectively). It was observed that Asian men smoked an average of 2.5 more cigarettes per day than Asian women, whereas Latino men smoked 1.5 more cigarettes per day in comparison to Latino women. The data also established that both prevalence and frequency of smoking increased with the duration of US residence among Asian immigrants. Only frequency of smoking increased in immigrants from Latin America. Additionally, it was noted that regardless of the duration of time spent in the US, immigrants who formed strong connections like English language proficiency and acquiring citizenship benefited from diminished smoking. The researchers recognized that the reason for reduced smoking behaviour may be due to the fact that these immigrants have decreased stress levels and have higher socioeconomic status (SES) (Reiss et al. 2015).
Among females, it was observed that women from Asia and Latin America who migrate to the US tend to experience a higher level of smoking post-immigration compared to their male counterparts, this could be attributed to stigma associated with smoking in their home countries.
20 2.2.4 Immigrants in Finland
As of 2016, out of the total population of Finland of 5,503,297, the number of people with country of birth in foreign countries with mother tongue other than Finnish, Swedish or Sami stands at 295,276 and the number of immigrants in Finland with country of citizenship other than Finland stands at 243,639 (Statistics Finland 2016). This percentage of Finland’s total population ranging between 4.4% and 5.3% can be considered as the immigrant population (Statistics Finland 2018).
As per the Migrant Health and Wellbeing Study (Maamu) carried out in Finland by the National Institute for Health and Welfare (THL), the duration of residence in the host nation negatively influences immigrant’s health and wellbeing. Coupled with the prevailing health and living circumstances, the life perspective of immigrant populations and their competence to endure life’s day-to-day endeavors is possibly impacted by distinct psychosocial elements, such as the extent of integration and the experiences of life’s preceding stages (Paakkanen et al. 2013).
2.2.5 Acculturation
Acculturation, by definition, is convoluted and multi-dimensional mechanism through “which foreign born individuals adopt the values, customs, norms, attitudes, and behaviors of the mainstream culture” (Redfield et al. 1936, Gordon 1964, Chen et al. 2000, Unger et al. 2000, Shelley et al. 2004).
It is the mechanism of adjustment that immigrants endure when they shift to a newer habitat and culture (Williams & Berry 1991), affecting them on some plane, irrespective of their nationality, country of immigration to or the status of their immigration category and hence, strenuous locating factors to intercede in the progress of chronic diseases and consequential adverse health outcomes (Hall & Cuellar 2016). Yet in reality, the concept of acculturation is reduced to bare single indicators such as proficiency or fluency in native language, status of immigration or duration of residence in host country (Shelley et al. 2004).
2.2.5.1 Impact on smoking
Though there was correlation established between acculturation and tobacco dependence among Arab-Americans (Al-Omari & Scheibmeir 2009) yet, other studies that scrutinized tobacco usage behavior and acculturation utilizing a range of indicators among different ethnic groups, have
21 borne diverse outcomes (Marin et al. 1989, Wiecha et al. 1998, Perez-Stable et al. 2001, Yu et al.
2002). The precise significance and impact of integration or acculturation is quite hard to quantify as immigrants have the tendency to imitate the attitudes of the society in which they reside (Marin et al. 1990). As immigrants become “more acculturated”, degree of tobacco usage altered (Haddad et al. 2012).
Coherent discrepancy was established between males and females in a study conducted among immigrants in North America (US and Canada), Great Britain, Germany, Netherlands, Norway, and Australia wherein probability to smoke was more among women who were more acculturated than less acculturated women, but contradicting results were observed amid men (Reiss et al.
2015). The smoking rates differed drastically between smokers in mainland China and Chinese- Americans, hence indicating linkage between tobacco usage behaviour and acculturation (Shelley et al. 2004). Studies displayed association between acculturation and smoking among Asian- Americans (Ma et al. 2004, Shelley et al. 2004, An et al. 2008, Rosario-Sim & O’Connell 2009, Li & Delva 2012), negatively among men and positively among women (Hofstetter et al. 2004, Kim et al. 2007, An et al. 2008, Choi et al. 2008, Zhang & Wang 2008). Positive association was established among Hispanic and Korean women. Among Chinese-Americans, conventional orientation influenced current smoking patterns whereas in adolescents, it resulted in the onset of smoking habit (Moeschberger et al. 1997, Perez-Stable et al. 2001, Chen et al. 1999a, b, Lee et al.
2000, Ma et al. 2004, Shelley et al. 2004, An et al. 2008, Rosario‐Sim & O'connell 2009, Li &
Delva 2012). Tobacco usage post-immigration, depreciated by 50% in men while it surged in women among immigrants from Korea and Mexican-Americans (Caraballo & Lee 2004, Choi et al. 2008). Daily cigarette consumption rate among Hispanic males was elevated in more acculturated than the less acculturated (Marin et al. 1989). However, among better accultured Arab-Americans, nicotine dependency dropped (Al-Omari & Scheibmeir 2009).
Within the same immigrant population, ramification of acculturation on smoking lacks homogeneity, probably differing in genders (Lara et al. 2005) and may be miniscule when other interactive biological, environmental and socio-economic determinants conclude tobacco usage pattern (NCCDPHP 1998).
22 2.2.5.2 Length of Stay
A study was undertaken to analyze transition in smoking by duration of residence among immigrants in Germany and correlated them to the “smoking epidemic” model and the acculturation theory. Data and research findings from a longitudinal survey (German Socio- economic Panel) was utilized. Immigrants were classified by the country of birth (Turkey:
respondents n = 828, observations n = 3871; Eastern Europe: respondents n = 2009, observations n = 7202; non-immigrants: respondents n = 34,011, observations n = 140,701). Available data on smoking status for nine years between 1998 and 2012 were included in the study. Length of stay (LOS) in years, was utilized as proxy marker for acculturation. Smoking prevalence, prevalence ratios and a random intercept multilevel logistic regression model was calculated. Study outcome showed that with each year of dwelling in Germany, smoking prevalence increased among women from Turkey (OR = 1.14 (95% CI = 1.06–1.21)) and slightly decreased among men. Turkish women who recently immigrated smoked less than non-immigrant women (0–5 years: SPR = 0.25 (95% CI = 0.10–0.57)); Increased LOS converged prevalence (31+ years: SPR = 1.25 (95% CI = 1.06–1.48)). Amidst immigrants from Eastern Europe, no compelling variations were evident. It was concluded that immigrants from Turkey “import” their smoking culture from a country where smoking is in earlier stages. With increased LOS, smoking moves on to a later stage.
Compelling association prevail between the duration of stay in the host country and prevalence of smoking in Chinese-Americans and Arab-Americans (Thirandam et al. 1998, Averback et al. 2002, Haddad et al. 2012). In the study conducted in Korean-Americans and Chinese-Americans, immigrants who lived for less than a decade were 12.5 times more probable to be a current smoker than those who dwelled a decade or longer (Kim et al. 2000, Shelley et al. 2004). Among Arab- Americans, age at which the immigration occurred too had an impact (Haddad et al. 2012).
Receptivity to preventive or precautionary messages are influenced by the duration of stay (Bodenmann et al. 2005). Regardless of the age of immigration, serious cessation attempts too increased with every year of stay though daily rate of smoking too increased among Arab- Americans (Al-Omari & Scheibmeir 2009, Haddad et al. 2012).
23 2.2.5.3 Education
Though smokers were knowledgeable to the hazards pertaining to smoking when compared to non-smokers, yet the level of education among the immigrants displayed varied results when it was associated with tobacco usage. Higher rate of smoking was evident in Somali-Americans with higher level of education whereas smokers among Vietnamese-Americans possessed lower education level (Shelley et al. 2004, Chan et al. 2007, Guiliani et al. 2012). Arab-Americans with least education levels smoked for longer duration of period (Rice & Kulwicki 1992).
2.2.5.4 Local language proficiency
Fluency in the local language indirectly affected immigrant’s knowledge of the adverse effects of smoking and possessed better access to preventive messages, measures and healthcare professionals than those that were not that well-assimilated into the local society and lacked language proficiency (Ciampa 1996, Bodenmann et al. 2005). In the studies conducted in the US, positive correlation between English language fluency and smoking was evident in men among South-Eastern Asians and Hispanics but, didn’t have an impact in Chinese and Vietnamese immigrants (Marin et al. 1989, Coreil et al. 1991, Ciampa 1996, Moeschberger et al. 1997, Wiecha et al. 1998, Perez-Stable et al. 2001, Yu et al. 2002).
2.2.6 Smoking knowledge, attitudes and practices among immigrants 2.2.6.1 Knowledge
An intimate nexus persists between smoking behaviour, personal health beliefs and cultural backdrop that an immigrant hails from (CDC 1987, Sheridan et al. 1993, Rogers et al. 1995, Pérez‐
Stable et al. 1998, Klonoff & Landrine 1999, Wilkinson 1999, Crampton et al. 2000, Shankar et al. 2000).
Smokers are oblivious to the interrelationship between smoking and diseases such as lung diseases primarily due to inadequacy of knowledge and awareness and hence, discern themselves to be less vulnerable to the smoking hazards (Oncken et al. 2005, Roddy et al. 2006, Siahpush et al. 2006, Yan et al. 2008). The probability of having never smoked was directly proportional to the increase in knowledge. Cigarettes with lower tar and nicotine content are perceived by the current smokers to be linked to depreciated susceptibility to cancer and hence, resisted to smoking cessation
24 (Shelley et al. 2004). Perceived benefits of smoking were chosen over the withdrawal symptoms by those with education from lower level and high-school, than the better educated (FitzGerald et al. 2015).
According to Bodenmann et al. (2005), immigrants displayed 3.2 times more ignorance of hazards of smoking as compared to native Swiss nationals. This was observed markedly among Eastern European immigrants than the Asian and African immigrants. Despite being knowledgeable about the hazards, Chinese immigrants in Canada displayed colossal rate of smoking primarily due to cultural beliefs and social norms (Ho et al. 2003, Gupta et al. 2006, Chen 2008, Wakefield et al.
2008, Wong et al. 2008, Gu et al. 2009, Yu et al. 2009, Burton et al. 2010, Yang et al. 2010).
Though majority (61.5%) of Chinese immigrants in Vancouver possessed knowledge with regards to smoking-related cardiac and pulmonary illnesses yet smoking continued in over 26% of the current smokers. Hazardous to children, odour issues and headaches were specified as the other detrimental effects during the study (Chen et al. 2001, Poureslami et al. 2015). Among Chinese- Americans, though the literacy rate was high, overall knowledge level was meagre (Shelley et al.
2004). Smokers who were speakers of Mandarin were more inclined to incite others to terminate smoking than smokers who were speakers of Cantonese language (FitzGerald et al. 2015). This implies the effect of the native region where the language was spoken and culture that the immigrant smoker hails from rather than the language they spoke in host country. Among Korean immigrants in the US over 90% men were knowledgeable of comorbidity such as bronchitis, emphysema and carcinomas associated with smoking, though knowledge regarding throat and oral carcinomas and cardiac ailments ranged between 70% and 68% (Kim et al. 2000).
Vietnamese immigrant smokers in the US, in some studies were found to be less knowledgeable about hazards of smoking and possessed belief that it bestowed beneficial traits (Jenkins et al.
1990, Wiecha et al. 1998, Ma et al. 2002, Ma et al. 2003, Ma et al. 2005a, b) and in some other studies, knowledge levels were found to be high (CDC 1988, Brownson et al. 1992, Chan et al.
2007). Knowledge of effects of smoking on health ranged between 70% to 90% among studies on Vietnamese-Americans and other Asian-Americans (Jenkins et al. 1990, Wiecha et al. 1998, Ma et al. 2005a, b). 59.3% of Arab-Americans were unaware of hazards and lesser than 30% were concerned of effects on their health due to smoking. Though 21.7% received information about the smoking ill-effects from their physicians, yet 54.6% of the respondents received the same from
25 the media (Haddad et al. 2012). High rates of usage of culture-specific tobacco was observed in South-Asians in the UK who possessed poor knowledge level of the health risks involved due to its usage (Vora et al. 2000).
The level of knowledge regarding the hazards of Secondhand Smoke (SHS) varied between smokers and non-smokers wherein smokers were less knowledgeable (Jenkins et al. 1990, Chen et al. 1993, Wiecha et al. 1998, Ma et al. 2003). Women in general, had a better knowledge and less tolerance than men and a similar trend observed in subjects with graduate degrees than those with lower educational levels. Awareness of hazards of SHS on non-smokers among Asian- Americans was more evident in Chinese - 91.5% with lower tolerance than Vietnamese - 83.6%, Cambodians - 80.8% and Koreans - 75.7%. The impact of SHS on children was evident among Korean - 95.8%, Vietnamese - 95.4%, Chinese - 93.6% and Cambodians - 83.3% (Ma et al. 2005a).
2.2.6.2 Attitudes
2.2.6.2.1 Influence of Beliefs
Out of many factors that instigate Chinese-American smokers to turn regular are the beliefs in almost 62% of smokers was that smoking “relaxed them” and “helped them feel less stress”, also when “they were having a break” or when “they were bored” with most having the perception of helpfulness through smoking to allay anxiety and stress. Among men, smoking helped to cope with the feeling of boredom and better connectivity with peers. It is significant to observe that no differences were singled out between age, gender or language factions (FitzGerald et al. 2015).
Among African-Americans, American-Indians, Alaska natives, Asian-Americans and Pacific islanders and Hispanics, as observed in the study by Benowitz et al. in 1998, smoking was primarily associated with psychological stress, depression and just as with general smoking population, environmental elements such as tobacco marketing-advertisements and smoking peers.
Among the South-Asian community in the UK, there is a high degree of perception of health and medicinal benefits of usage of tobacco. This could be attributed to use of smokeless tobacco with arecanut, the digestive, oral and other health perks such as cognitive ones - increasing alertness, memory improvement that is supposedly associated with it emanating from culture and religions originating in South-Asia. Many tobacco products as these were believed to be antiseptic, astringent, local anesthetic, to possess nutritional properties, aid in digestion, sleep, or efficient as
26 breath freshener, mouth cleanser. Despite the evidence backed scientific findings disproving these beliefs, they exert strong imprint on these kinds of “culturally-specific” tobacco use among South- Asian immigrants, withstanding time and migration resulting in subsequent transmission to future generations (Gan 1998, Strickland 2002, Williams et al. 2002, Longman et al. 2010, Mukherjea et al. 2012).
Among Chinese-Canadians, almost half of the smokers smoked habitually with no perceived benefits, with almost quarter of current smokers and 13.4% former smokers stating smoking as a tool to relax. Elevated concentration level, aid to deal with COPD-related anxiety and stress were other perceived benefits. Difficulty in quitting due to positive feelings and the need to replenish the body with nicotine due to years of smoking was the belief of current smokers (Mikkelsen et al.
2004, Hilberink et al. 2006, Eklund et al. 2012, Poureslami et al. 2015). 68% of Korean-American smokers smoked as a habit, wherein 23% smoked to relax, 8% accepted the addiction and 37.6%
of those who had occupation as business, to socialize (Ma et. al 2005, Kim et al. 2000). Smoking commands wide acceptance among men (one-third) unlike considered “inappropriate” for women among Vietnamese-Americans with almost 42% of current smokers approving practice of the habit with friends wherein 22% of former smokers disagreed. Current smokers displayed positive attitude towards the habit by 3.77 times than the non-smokers towards the practice of smoking with friends wherein smoking was considered, a “manly trait” (Wiecha et al. 1998, Ma et al. 2005, Chan et al. 2007). Cultural influence to greet men with cigarettes played a pivotal role in the smoking culture and refusal of the offering was termed as impolite (Efroymson et al. 1998).
Among Somali immigrants in the UK, onset of smoking was closely associated with peer pressure, family influences, socializing, to present oneself as fashionable, to address stress or loneliness.
Somali women smokers, deeply influenced by social elements such as to seem fashionable, to socialize or to have fun or to address loneliness, were stigmatized for their smoking habit. Many did undertake smoking to seem “civilized”. “Prestige” (54.6%) and inherent wish to be a part of the new culture (51.3%) resulted in onset of smoking in more than half of the smokers (Giuliani et al. 2008, Haddad et al. 2012).
27 2.2.6.2.2 Influence of Religion
Religion plays a pivotal preventive role against smoking onset or behaviour. Christians (both catholic and protestant) were less probable to smoke unlike those who professed a non-Christian religion or had no religion that were 16.6 times more probable to be a smoker (Kim & Lee 1990, Kim et al. 1996, Kim et al. 2000). Islamic principles and belief in Islamic prohibition of tobacco usage greatly affected and acted against current usage and acted as a deterrent against onset or future intention to use especially among Somali and Arab immigrants (Giuliani et al. 2008, Giuliani et al. 2010, Sayeed 2011, Giuliani et al. 2012, Yong et al. 2013). Mode of tobacco use too varies depending on the religion.
As observed among the U.K immigrants, smoking including culturally-accepted hookah is more acceptable among South-Asian muslims and Arab women (due to lesser stigma associated with it), while consumption of smokeless tobacco in the form of “paan” is widely practiced among the followers of Hinduism (Kandela 2000, Williams et al. 2002, Bush et al. 2003, Tamim et al. 2003, Maziak et al. 2004b, Maziak et al. 2004c, Knishkowy & Amitai 2005, Shamo et al. 2010, Mukherjea et al. 2012). Psychosocial factors too greatly affected tobacco usage as seen among Somali-Americans and African-Americans (Pleis & Lethbridge-Cejku 2007, CDC 2011).
2.2.6.2.3 Influence of Culture, Ethnic Identity, Family and Social network
Smoking as a behaviour and habit, is acceptable both socially and culturally, in the Middle-Eastern or Arab countries and hence, there exists an extremely high rate of smoking prevalence in these countries. The tobacco use by Arab-Americans, in whom cultural attitudes plays a predominant role and positively correlated to the tobacco usage by family members, friends or peers, social network wherein usage of tobacco in some form (smoke cigarettes or hookah/sheisha, chew tobacco) is observed in individuals that have parents, family members, friends or peers who smoke (Memon et al. 2000, Haddad & Malak 2002, Islam & Johnson 2003, Maziak et al. 2004a, Maziak et al. 2004c, Giuliani et al. 2008, Smith-Simone et al. 2008, Al-Omari & Scheibmeir 2009, Alzohairy 2012, Giuliani et al. 2012, El Hajj et al. 2017). Hailing from a similar culture as Arabs, though tobacco usage in Somali-Americans varied depending on age, gender or levels of education, influence of friends held a sway in the tobacco usage of an individual among both genders (Giuliani et al. 2008, Giuliani et al. 2010, Giuliani et al. 2012).
28 Many among the immigrant communities used traditions, customs and celebrations as a gateway to use culturally specific tobacco as a mode to preserve native culture. One also utilized the tobacco usage as an expression of distinct ethnic identity or ethnicity from that of host population or culture. It was noted that such culture specific tobacco and its usage was free from stigma within the immigrant communities (Vora et al. 2000, Mukherjea et al. 2012).
2.2.6.3 Practices
Prevalence of smoking was less than the natives in African-Americans whose satisfaction with smoking was low and were more self-assured of their ability to quit. Hispanics in the U.S and Asian-Americans had strong motivation to quit smoking in order to protect their family from second hand smoke (Vander Martin et al. 1990). Somali-Americans believed that willpower alone could accomplish smoking cessation (Giuliani et al. 2012). Involvement and integration of religious leaders and institutions was expected to bore better cessation results in more conservative immigrant societies (Giuliani et al. 2008, Giuliani et al. 2010).
79% of Chinese-Americans backed enforcing smoking ban in workplaces and 94% in public spaces. Policies promoting smoke-free workplace and public space was positively correlated with one being either a former smoker or a non-smoker (Shelley et al. 2004).
The 1992 California Tobacco Survey (CTS) demonstrated that 43.2% of Asian-Americans or Pacific Islanders (AAPIs) were in favour of having smoke-free home as compared to 39.5% of Hispanics, 32.6% of Blacks and 37.4% of non-Hispanic Whites. By the year 1999, Hispanics took the lead in reporting smoking bans at home than other races and immigrants (Gilpin et al. 2002).
In the 2002 survey conducted by Department of Health and Mental Hygiene in New York city, it was evident that complete household ban was enforced by 62% of Asian-Americans and 69% of Hispanic immigrants. Exposure to ETS at homes was reported by 44.9% Vietnamese-Americans, 42% Korean-Americans and 29.7% Chinese-Americans (Ma et al. 2004). Among Chinese- Americans, complete ban was reported by 66%, partial ban by 22%, no-ban by 12% and 38% of the current smokers reported complete ban (Shelley et al. 2006). In contrast to earlier research findings of 47%, only 12% of current smokers among Vietnamese-Americans allowed smoking within their homes as compared to US national rate of 26% (Ma et al. 2005a, b, CDC 2006, Chan et al. 2007). Among both smokers and non-smokers, elevated levels of awareness pertaining to
29 hazards of ETS was associated with smoking bans within households (Kegler & Malcoe 2002, Pizacani et al. 2003).
Tobacco usage pattern isn’t dependent on a single factor but a complex conglomeration of multiple factors such as SES, attitudes emanating from culture, stress and anxiety, acculturation, targeted marketing of tobacco products, beliefs and perceptions of the immigrant community (Benowitz et al. 1998).
2.2.7 Smoking cessation interventions among immigrants
A study was conducted to systematically review latest literature on smoking cessation in racial/ethnic minority groups. The study concentrated on smoking cessation intervention trials and scrutiny of elements associated with cessation. Ethnic/racial minorities reported greater quitting rates compared to the natives. It was observed that factors such as menthol smoking, low usage of pharmacotherapy and decreased willingness to quit, affected the outcome on smoking cessation.
A study done on African-Americans revealed that abstinence rates were reduced compared to their white counterparts. Schnoll et al. (2011) noted that a 12-week open-label varenicline plus counseling program was ineffective in making the minority group quit tobacco. Smoking cessation interventions when administered to US hispanics, it was observed that 8 weeks of nicotine patches brought a drastic reduction in cessation rate, however the results were statistically insignificant.
Varenicline, nicotine patches or placebo varenicline was used. It was observed that varenicline was most effective intervention among light Hispanic smokers (Ebrahim et al. 2000, Borrelli et al. 2010).
Amid smokers who are mindful of the adverse effects of smoking, 3 out of 4 smokers displayed interest in relinquishing smoking. One of the pivotal responsibilities of a country’s health care system is to address and treat nicotine dependence. This encompasses disparate approaches such as clear clinical counseling, medications and quit lines. The price of these modes differs, however and these mechanisms aren’t very efficient. It is imperative to customize and match the treatment means to the local and cultural context as well as to client’s present requirements. Recurrent consultation is important in reinforcing the essentiality of quitting smoking at every clinical visit.
Moreover, counseling by health workers elevates quit rates. This intervention is comparably cost- effective, because it is part of the existent health care services which are utilized by the bulk of the
30 smokers. These interventions offered by health care providers are effective as they are respected by the masses and possess good working relationship with the smokers. Furthermore, it is imperative to envision provision of free-of-charge quit lines services from any telephone. Indeed, old telephone line systems that reciprocated only to incoming calls showed very compelling outcome.
Supplementing clinical counseling and quit lines for consultation, medication can be impregnated as an effective treatment. Medication comprises of nicotine replacement therapy (NRT) (patches, gum, sublingual tablets, lozenges, inhalers and nasal spray) and prescription drugs such as Bupropion and Varenicline. In general, medication is pricier than medical counseling and quit lines. Nevertheless, the evidence displayed that it can double or triple cessation rates.
Internet-based smoking cessation intervention was effective in comparison to written self-help in a sample of Korean Americans (McDonnell et al. 2011). A randomized controlled trial (RCT) was conducted by Kim et al. (2012) to compare culturally-tailored cognitive behavioral therapy (CBT) for smoking cessation and medication management among Korean-Americans which established that culturally-tailored CBT was more competent among Korean-Americans.
Smith et al. inspected the efficacy of a culturally custom-made versus standard smoking cessation treatment in American Indian/Alaska Native tribal community. Four individual counseling visits and of varenicline dosage of 12 weeks were received by all participants. Cessation rates ranged from 14 to 44 % across the six smoking group assessments through 6-months post cessation. There was no difference between conditions. Post hoc analyses determined that the 6-month abstinence was correlated with early stoppage, older age, lower intensity of daily smoking at baseline and little to almost non-existent smoking amidst smokers (Kim et al. 2012).
For the health promotion programmes to prevail, one must take into account of the root cause for the commencement of smoking and the knowledge, attitude, beliefs, perceptions of the smokers especially among the youth where the habit takes off and in depth scrutinize the patterns, behaviour and habits (FitzGerald et al. 2015). This approach has proved efficient when enforced to modify habits or behaviors associated with smoking through promotions of constructive perceptions and self-efficacy enhancement (Song et al. 2009, Harris et al. 2012, Arval et al. 2013).
31 3. AIMS OF THE STUDY
This study focused on following aims:
Assessing knowledge of subjects about health effects of smoking,
Investigating their attitudes and perceptions of smoking and smoking-cessation,
Tracing their practice patterns,
These phenomena were explored in the foreground of their socio-demographic factors.
32 4. MATERIALS AND METHODS
4.1 Study design
Cross-sectional study design employing qualitative structured in-depth interviews and phenomenographic approach.
4.2 Study setting
The study was conducted in the Helsinki Capital Region in Finland.
Helsinki, Vantaa, Espoo and Kauniainen, the four municipalities having the city status within Helsinki Capital Region, constituted the sampling frame. As of 2014, the total population of the study region is approximately about 1.1 million. Helsinki Capital Region was chosen as the study setting due to higher number of immigrants in this region as compared to the rest of Finland.
Finland has a total population of 243,639 immigrants.
4.3 Study subjects
The study subjects were former smokers and those who currently smoked and did not comprise of never-smokers (those that never ever smoked even a single cigarette), comprised of adults between 28 to 44 years of age and speakers of English language, residing in the Helsinki Capital Region during this study. The participation in this research was voluntary in entirety.
4.4 Methodology
Prior to conducting the actual survey, a pilot study was done among English speaking immigrants attending a Swedish language school to assess the validity, feasibility and applicability of the questionnaire. The participation in this pilot study too was voluntary.
During the pilot study, subjects were granted provision to complete the questionnaire and the intent of the study was diligently elucidated to the participants. Results of the pilot study divulged that there was no ambiguity and that the language used was appropriate for the target study group.
An advertisement inviting volunteers who were former smokers and those who currently smoked, living presently in the Helsinki Capital Region was posted in the social media in various forums or groups in which the immigrants were members. Numerous subjects volunteered to participate
