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A qualitative study of Chinese Canadian fathers’ smoking behaviors: intersecting cultures and masculinities Mao, Aimei; Bottorff, Joan L; Oliffe, John Lindsay; Sarbit, Gayl; Kelly, Mary T Mar 25, 2015

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RESEARCH ARTICLE Open AccessA qualitative study of Chine5 aokane actkintedinclude: being male, being employed, married, and hav- among recent immigrant men from China (<5 years inMao et al. BMC Public Health  (2015) 15:286 DOI 10.1186/s12889-015-1646-0AustraliaFull list of author information is available at the end of the articleing less than high school education [5].In the US and Canada, a large and growing proportionof immigrants are from China. Chinese Canadians arethe second largest visible minority group in Canada,comprising 4% of the total population, and over 70% arethe U.S.) was 28.0% [10] although that is still higher thanthe smoking prevalence in the general American popula-tion (18.1%) [12]. Studies exploring Chinese men’s smokingpatterns in different parts of America provide the followingprevalence rates: 22% in Seattle [9]; 16.1% in Texas [10];24% in Delaware Valley and New Jersey [13]; 29% in NewYork City [14] and 16.2% [15] based on national surveydata. Despite these favorable trends suggesting reducedsmoking rates post immigration, nearly two thirds of male* Correspondence: joan.bottorff@ubc.ca2School of Nursing and Institute for Healthy Living and Chronic DiseasePrevention, University of British Columbia, 3333 University Way, Kelowna, BC,Canada3Faculty of Health Sciences, Australian Catholic University, Melbourne, VIC,ing socially in China [2-4], the predictors of tobacco useMethods: In this qualitative study, semi-structured telephone interviews were conducted with 22 Chinese Canadianfathers who smoked or had recently quit smoking, and had at least one child under the age of five years old.Results: The Chinese fathers had dramatically changed their smoking patterns due to concern for their children’shealth and social norms and restrictions related to smoking in Canada. The facilitators and barriers for men’s smokingwere intertwined with idealized masculine provider and protector roles, and diverse Canadian Chinese cultural normsrelated to tobacco use.Conclusions: The findings have implications for the development of future smoking cessation interventions targetingChinese Canadian immigrant smokers as well as smokers in China.BackgroundChina has the largest number of tobacco smokers in theworld and the majority of smokers are men [1]. Surveydata in China indicates the extent to which smoking is agendered health concern: 52.9% of adult men smoke,compared to 2.4% of adult women [1]. As a culturallyaccepted practice among men, and conduit for interact-foreign born [6]. In the US, Asian Americans representthe second largest immigrant group, and among foreignborn Asians, 23% are Chinese, comprising more than 2.5million people [7]. There is evidence that immigrationmay influence reductions in smoking because the rate ofsmoking prevalence among Chinese immigrants appearsto be much lower than their counterparts in China[8-11]. For instance, in the U.S. the smoking prevalencesmoking behaviors: intersmasculinitiesAimei Mao1, Joan L Bottorff2,3*, John L Oliffe4, Gayl SarbitAbstractBackground: China is home to the largest number of smsmoke. Given the high rates of Chinese immigration to Cof immigration on Chinese smokers. Reduced tobacco usUnited States; however, little is known about the social fawhere tobacco control measures have denormalized smothis Canada-based study was to explore the smoking-rela© 2015 Mao et al.; licensee BioMed Central. ThCommons Attribution License (http://creativecreproduction in any medium, provided the orDedication waiver (http://creativecommons.orunless otherwise stated.ese Canadian fathers’cting cultures andnd Mary T Kelly5ers in the world; more than half of the male populationada and the USA, researchers have explored the effectmong Chinese immigrants has been reported in theors underlying men’s smoking practices in settingsg, and in the context of fatherhood. The purpose ofexperiences of immigrant Chinese fathers.is is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andiginal work is properly credited. The Creative Commons Public Domaing/publicdomain/zero/1.0/) applies to the data made available in this article,Mao et al. BMC Public Health  (2015) 15:286 Page 2 of 10Chinese immigrants who are current smokers have no in-tentions to quit smoking in near future [13]. Little researchis available regarding smoking prevalence among ChineseCanadian immigrants.In comparison, within Canada, 21.8% of young menaged 25 to 34 years are current smokers [16]. Similarly,in the US, 26.8% of men aged 25–44 are smokers, thehighest consumption category aggregated by age and sex[12]. In China, the rate of smoking prevalence for menaged 24–44 years reaches 59.3% [1]. It is noteworthy thatthese age ranges also represent the stage of life at whichmen become fathers. As such, although immigrant Chinesemen enter a society in which tobacco use is denormalized,their Canadian and American male peers are modelinghigher than average levels of tobacco consumption (i.e.,16% of the Canadian adult population are current smokers[16]), further challenging Chinese men’s motivations toreduce their tobacco use after immigration.Tobacco use, culture and masculinitiesResearch from different cultures has revealed that to-bacco use is universally associated with gender-relatedfactors. For example, across Asian countries, includingChina, men’s smoking is socially accepted, while women’ssmoking is discouraged; in contrast, in the Western world,women smoke at almost the same rate as men [17].Despite these significant differences in smoking preva-lence between men and women in Asian countries,little research has explored gender-related factorsunderlying these smoking patterns. Research studies inthe West have shown that men’s smoking is closelyrelated to masculine ideals, such as independence,physical resilience to harmful substances and capacityto endure risk-taking [18-21], while women’s smokingsymbolizes personal freedom, sexual attraction, andemancipation from gender norms [22,23].In China, smoking has provided a strong positive sig-nifier of masculinity and an important way to embodyidealized notions of manhood and enact authority [24].As a culturally accepted practice, smoking is closelyrelated to social currency and masculine capital [2,3,5].As such, smoking and cigarette gifting are an importantcomponent of men’s social interactions and businesstransactions, even among those residing in rural areas[3,4,25], and these gendered practices challenge tobaccoreduction efforts in China [26].Despite men’s reliance on smoking to fulfill genderedroles, there is some evidence that Chinese men arewilling to decrease their smoking in the context of par-ticular lifecourse events. For example, in one study itwas reported that the prevalence of second-hand smokeexposure was 55.9% among women before pregnancyand decreased to 41.9% during pregnancy [27]. Amonghusbands who ever smoked, 14.4% stopped smokingbefore pregnancy, 38.1% changed their smoking behav-iors during pregnancy, and 10.7% quit smoking afterpregnancy [27]. However, men’s changes in smokingbehavior during pregnancy were temporary, and mostfathers started smoking again by the time their childrenturned two years old [28,29]. It has been suggested thatchanges in health-related behavior associated withbecoming a father may be related to men’s fulfilment ofsocially subscribed expectations to meet the needs of adependent [30]. Despite this, among Chinese men itappears that the functions that smoking serves in socialand economic encounters and limited awareness of itshealth consequences [25] may create a compelling con-text to resume smoking to maintain traditional bread-winner roles and social status in an environment wherethe majority of men smoke.In Canada, there is also emerging evidence that father-hood may be associated with changes in smoking patterns.Qualitative interviews with fathers who smoke haverevealed that engagement in fathering often heightens dis-sonance regarding continued smoking; as men’s alignmentwith masculinities shifts to being protectors and providers,they seriously consider and sometimes try to quit smoking[31-33]. These shifts need to be understood in the contextof tobacco control policies in Canada which have sig-nificantly reduced smoking levels, and created a socialenvironment where smoking is denormalized and in-creasingly stigmatized [31,34]. This, along with theprominence of tobacco control messages about thehealth effects of smoking, challenges men’s continuedsmoking as they incorporate contemporary identitiesassociated with fathering [31]. Following immigration,Chinese men are exposed to new social environments intheir host countries that may influence their smokingpractices. Li [35] has observed that despite some reduc-tions in smoking, there appears to be an enduringinfluence of the Chinese smoking culture on Chineseimmigrant smoking. However, how changes in socialenvironments associated with immigration play a role inshaping Chinese father’s smoking is not entirely clear.The purpose of this Canada-based study was to describethe intersections between cultures and masculinities amongChinese Canadian immigrant fathers who smoke.MethodsThis study was conducted using a qualitative interpretiveapproach, guided by grounded theory methods [36].Men were recruited if they met the following criteria: 1)self-identified as a Chinese immigrant or a ChineseCanadian; 2) were expecting a child or had a child underfive years old; 3) were currently smoking or had quitsmoking in the past 5 years; and 4) had lived in Canadafor at least 6 months. Bilingual recruitment ads were dis-tributed to Chinese organizations in the lower mainlandof British Columbia, Canada and posted on Chinese on-line forums. Among the 22 Chinese fathers recruited, 12resided in Ontario, two in Quebec, and eight in BritishColumbia, representing the three most populated prov-inces in Canada. The sample was characterized by a var-iety of backgrounds in terms of demography and smokingpatterns (Table 1). All the fathers were first-generationimmigrants; two migrated to Canada with their parentsbefore 18 years of age, and the other 20 migrated after age18. The two early immigrants identified their first lan-guage as English; the others identified Chinese as theirfirst language.The study was reviewed and approved by the Univer-sity of British Columbia Behavioral Research EthicsBoard. All the participants provided informed consent.They were offered an honorarium of CAD$50 to ac-knowledge their contribution to the study.Data collectionSemi-structured interviews were conducted via tele-phone with all the participants except one, with whom aface to face interview was conducted. Canada is a vastcountry in terms of geographical size and telephoneinterviewing maximized our ability to reach Chinese im-migrants from diverse backgrounds. Also, telephoneinterviewing is ideal to explore sensitive issues because itpermits more anonymity and privacy than face to faceinterviewing [37]. The interview questions focused onexperiences of smoking in the context of fathering andmen’s efforts to quit smoking (Table 2). Probes andfollow-up questions were used to encourage the fathersto elaborate on their smoking patterns before and afterthey came to Canada, and how their smoking had changedaround their partners’ pregnancies. A brief questionnairewas used before the start of the interview to collect basicdemographic information and smoking patterns. Theinterviews were conducted by a bilingual researcher(first author). Two of the interviews were conducted inEnglish while the other 20 were in Mandarin. The inter-views lasted from half an hour to 1.5 hours, and onaverage were one hour.Data analysisTable 1 Demographics and smoking history of theparticipantsAge (years) 37.8±5.2 (28 to 46)EducationJunior/middle school 1High school 0Non-university (collage, vocational,technical, trade etc.)3Mao et al. BMC Public Health  (2015) 15:286 Page 3 of 10Bachelor’s degree 13Master’s degree or over 5Years in Canada 6.8±4.4 (0.5 to 13)OccupationClerical/administrative 5Construction/manual labour 7Technical/skilled/professional/trade 7Unemployed (student) 3Marital statusMarried 21Divorced 1Number of children1 132 83 1Amount smoked<10/day 710-20/day 3>20/day 0Quit smoking 12All interviews were digitally recorded, translated intoEnglish and transcribed. A bilingual research assistantwith Chinese and English proficiency translated theinterviews and the translations were checked by thebilingual researcher (first author). An interpretive the-matic analysis using constant comparison was conductedwith transcribed interviews [36]. A coding frameworkTable 2 Interview questionsTopic areas QuestionsExperiences infatheringTell me a little about your family.• Tell me about your experience when you firstbecame a father.• What kind of father do you think is a goodfather?• How have things changed (at home, atwork) since you have had a child?Who looks after your child/ren?• How are you involved in looking after yourchild/ren?Experiences withsmokingTell me about your smoking.➢ How is your smoking at home? Are thereany rules on smoking in your home?➢ How is your smoking in your car? At work?➢ How has becoming a dad changed yoursmoking?What helped you the most to quit smoking?What were the barriers?How are Chinese fathers different from theCanadian fathers in terms of smoking practices?What do you think causes the differences?to two life changes: immigration and becoming a father.Mao et al. BMC Public Health  (2015) 15:286 Page 4 of 10Although only one Chinese father quit smoking soonafter he moved to Canada, the majority of the othersreduced the numbers of cigarettes smoked after immi-grating. The men described becoming a father as a moreinfluential factor than immigration, and one that led tomore quits and more significant smoking reductions.Participants had developed the habit of smoking out-side the home after they arrived in Canada, and thehome smoking ban was more strictly abided by thefathers during their partner’s pregnancy and the earlychildhood years. Despite reduced levels of smoking, the7 current light smokers (<6–7 cigarettes a day) werevague about their commitment to reducing or quittingtheir last few cigarettes.A variety of factors contributed to smoking cessationor continued smoking, as summarized in Table 3. Thesefactors were strongly influenced by and linked to themasculine ideals of fatherhood as a provider and pro-tector of children and family. Masculine ideals and be-haviors displaying masculinity are socially constructed,multifaceted, and dependent on specific and local socialcontexts [38] and, therefore, shaped the facilitators andwas developed by the research team based on their pre-vious experiences of research with Canadian fathers whosmoked and the readings of the first three interviews.Three members of the research team independentlyhand-coded these three interviews. Definitions for thecodes were established to facilitate coding. After com-parisons were made, the researchers refined the codingframework. Once the coding framework was finalized,the qualitative data management program NVIVO 8was used to code and retrieve data. Data coded to eachcategory were reviewed in detail, comparing and contrast-ing data from all participants to identify patterns in theChinese Canadian immigrants’ constructions of theirsmoking under the context of being fathers. The two par-ticipants who had migrated to Canada as children werecompared and contrasted with other participants who mi-grated as young adults to ensure they were not outliers.The research team reviewed and debated discordantnarratives to reach consensus on the interpretation of thefindings. Repeated narratives about men’s smoking wereevident and indicated data saturation was achieved.ResultsTwelve of the fathers had quit smoking (defined ashaving stopped smoking for at least a week); 10 fatherswere currently smoking, including the two participantswho had migrated at a younger age. All the fathers hadexperienced significant changes to their smoking relatedbarriers related to the fathers’ smoking practices indiverse ways (Figure 1). In the following section, therelationship between smoking, fathering and masculinityfor Chinese Canadian immigrant fathers is detailed.The masculine identity of protector and smokingBecoming a father was considered the most importantfacilitator for quitting or reducing smoking. Eleven ofthe 12 ex-smokers quit smoking when they learned thatthey were going to have children or when their childrenwere in infancy. Others had substantially reduced theirsmoking for their expected child or young children.According to the fathers, the message that exposure tosecond-hand smoke is harmful to pregnant women andyoung children had become commonplace. A 46-year-old father who had quit smoking said, “I can’t imaginethat there are men who still smoke around their wivesduring pregnancy.” Men’s changes in smoking were con-structed as voluntary behavior modifications, rather thanforced practices.Usually Chinese smokers developed a habit of smokingoutside the home as soon as they arrived in Canada, be-cause smoking is not permitted inside public buildings.A 33-year-old father, smoking 3–4 cigarettes/day, said:“We could smoke everywhere in China. Here no onesmokes inside buildings. Under such circumstances, wesmoke much less than we did in China.” The Chinesemen were willing to conform to Canadian smokingnorms, and extended the ban on indoor smoking in thepublic sphere into domestic spaces. Also, becoming afather strengthened efforts to maintain a smoke-freehome. For example, the majority of fathers stated theymade no exceptions to keeping their smoking outside,even during the cold Canadian winter months.The no-indoor smoking rule also applied to visitors intheir homes. A 33-year-old father who currently smoked15 cigarettes daily spoke of the rule in his home: “Here Ihave some friends who smoke. When they come to myhome they don’t smoke inside. We all go outside tosmoke. You don’t have to tell them to do so. That’s arule here”.This father’s narrative fulfills several purposes. Dem-onstrated is his knowledge of Canadian cultural normsand the stigma related to indoor smoking. Further, inemphasizing how he and his friends respected these“rules”, his concession also operates as a rationalizationfor his own continued outdoor smoking. It is implicitthat the “we” in his interview refers to male friends whoenjoy smoking together and that they have adjusted theirsmoking practices to reflect Canadian values.Involvement in childcare also increased the Chinesefathers’ determination to restrict their smoking at home.A 40-year-old father who smoked fewer than 10 ciga-rettes/week, said it was self-evident that more involve-ment in childcare would reduce smoking: “During thetime you are with your baby, you will be too busy tosmoke.” The fathers offered two reasons why ChineseCanadian fathers spent more time with their childrenthan their counterparts did in China. One reason relatedsocial status. However, Chinese Canadian fathers observeda different use of leisure time by Canadian fathers, as a44-year-old Chinese Canadian father who smoked 10Table 3 Facilitators and barriers to quitting smokingFacilitators N Barriers NConcern over impacts of smoking on children’s health 22 Light smoking 10Economic concern 20 Refusal of use of smoking cessation aids 9Different smoking environment between China and Canada 22 Having friends or colleagues who smoke 7Smoking cessation supports from wives and other people 14 Difficulty in getting rid of the habit 6Smoking cessation supports from health professionals 8 The need for coping stress, and killing time 8Concern over impacts of smoking on own health 11Mao et al. BMC Public Health  (2015) 15:286 Page 5 of 10to the observation that, in Canada, fathers tend to sharechildcare tasks with their wives; therefore, the Chinese'Canadian fathers shifted their own behaviors to align withthese contemporary domestic practices for Western men.Traditionally, there is a gendered division of family respon-sibilities in China: men deal with outside issues whilewomen are responsible for domestic tasks and childcare.Although the Chinese Canadian fathers stated that themain caregivers of their children were their wives or part-ners, they acknowledged that their increased involvementin childcare in Canada also reflected their fewer social net-works and financial resources.In China, it is usually the grandparents who take careof their grandchildren. In Canada, we can’t get ourparents to help with the childcare. It is very expensiveto hire a babysitter too. A babysitter’s salary is almostthe amount of my salary. [41-year- old father, smoking2–3 cigarettes/day].The other reason for increased childcare duties relatedto differences in men’s leisure activities between Chinaand Canada. In China, spending time with friends, col-leagues, and business partners was an important compo-nent of men’s pastime activities and a symbol of men’sFigure 1 The impacts of masculinity on smoking practices.cigarettes/day professed:In China, if a man spends much time at home he willbe regarded by other people as lacking a well-establishedsocial network. Canadian fathers tend to stay at home orgo on trips with their family on weekends. I am startingto develop the habit of travelling with my family now.This is something different from what I did in China, butI feel really good.Like him, other Chinese fathers did not challengeCanadian fathers’ involvement in family life; instead theyquestioned the image of the traditional Chinese father asan “absent father”. This questioning touches on the fun-damental contradiction of emphasized Chinese values offamilism and the lack of childcare involvement that isoften observed among Chinese fathers.Despite reduced smoking, some fathers reported smokingthroughout their partners’ pregnancies, although at a lighterlevel, fewer than 10 cigarettes a day. Several fatherswho had quit smoking during their partners’ pregnan-cies resumed smoking postpartum. These fathers wereable to reconcile their continued smoking with the role ofprotector. For example, a 44-year-old father, smoking 10cigarettes/day, boasted that his three-year-old daughterMao et al. BMC Public Health  (2015) 15:286 Page 6 of 10did not know he was a smoker: “In the last years, I havenever smoked at home. And I have always tried to hidemy smoking from my kid. I don’t think she knows I am asmoker”. Implicit here is the man’s denial that his con-cealed smoking will directly (via second-hand smoke) orindirectly (as a role model) impact his child. For this rea-son, some of the current smokers were vague in theircommitment to quitting their last few daily cigarettes. A40-year-old father who reported smoking fewer than 5cigarettes a day said: “To be honest, I have never thoughtto completely stop smoking one day, although that is theideal”.The masculine identity of provider and smokingIn most of the participants’ families, the wives wereeither full-time caregivers or worked part-time, while thefathers, as primary breadwinners, worked full-time orhad two part-time jobs. The career prospects of theChinese men were negatively impacted as a result ofimmigration. Although the men were relatively welleducated, the majority were unable to find suitable jobsthat matched their career training. As a result, they wereunderemployed, working as labourers or in lower skilledjobs with poor salaries. Nonetheless, the Chinese fathersseemed to agree that the first-generation’s hardships andsacrifices were inevitable: “Why have you left your hometown and come to a foreign country? There must be areason. You come here to seek a better life, so you willhave to invest in that”. (41-year-old, ex-smoker).The cost of more expensive cigarettes in Canada addedto the participants’ financial burdens. A 39-year-oldfather, smoking 1–3 cigarettes/day, made the compa-rison saying, “Generally a pack of cigarettes costs 10dollars in Canada. The cheaper ones are 6–7 dollars. InChina, a pack of cigarettes usually costs 10 RMB, whichis less than 2 dollars”.As providers for their families, the fathers also realizedthe importance of their own health. Although the fatherswere generally healthy, they became nervous if they didnot feel well. A 37-year-old father who smoked 6–7cigarettes/day said, “You are the father; you are the sup-porter; you have to take care of your family. If you getcancer from smoking, then you will be a liability to yourfamily!” The pressures of breadwinner status are appar-ent here; the fathers were acutely aware of how theirown health was the prerequisite for a better future fortheir children.Interestingly, the fathers who were currently lightsmokers (fewer than 10 cigarettes a day) were not con-cerned about the health risks of their smoking. Theyconnected the idea of “light” smoking with the idea ofnatural balance, declaring their smoking harmless. One33-year-old father, who currently smoked 3–4 cigarettesa day, said:There are two types of views on quitting smoking.One said it is good to quit because it is better for thehealth. The other said that you shouldn’t do it too fastbecause your body has got used to nicotine. I agreewith the second point. I suppose this reflects theChinese culture of shun-qi-zi-ran [following a naturalcourse without much change].According to the fathers, their bodies had establisheda balance with smoking. The complete withdrawal fromsmoking could disrupt the balance and might causehealth problems. This finding is in line with studies inChina indicating that some health professionals havesuggested smokers not quit completely or too suddenly[39,40]. This light cigarette smoking rationale might alsobe related to the popularity of the cigarettes marketed as“light” among Chinese people.As the family provider, the fathers also justified theirright to smoke. They expressed their loneliness in Canada,their stress associated with finding a job, and the frustra-tion caused by their job. A 46-year-old father who smokedfewer than 10 cigarettes a week expressed difficulty inquitting, but defended his smoking. Based on this father’spresentation, his smoking did not tarnish his family manimage, but rather, represented a hard-won reward:My wife doesn’t say anything about my smoking. Sheknows I need it. I don’t feel uneasy with my smokingas long as I have earned enough for my family to buyfood and clothes. To tell you the truth, I always givewife and two children the best and leave the worst tomyself. My wife and my eldest daughter have one cellphone each and their cell phones are more advancedthan mine.Evident here is the alignment to well established normsaround smoking and the self-sacrifice synonymous withmasculine virtues providing for others. Ever clear arebi-cultural values whereby the man’s consumerism reliedon and reflected a range of Chinese and Canadian culturalnorms.Masculine identity as an autonomous man and smokingSmoking, as a predominately male behavior, was reflectedin that none of the participants’ partners were smokers.The men described how their partners held negativeattitudes towards their smoking and often asked themto quit, which they acknowledged had played a role intheir changed smoking to a certain extent. However,they emphasized that the changes in their smoking pat-terns were their own decisions rather than concessionsto their partners. A 42-year-old father, who had quitsmoking three years ago when he learned that his wifewas pregnant, said: “I really think that this is somethingMao et al. BMC Public Health  (2015) 15:286 Page 7 of 10only depending on you. No matter how many people tellyou to quit, they can’t be there to watch you 24 hours”.Two fathers quit smoking partially due to advice theyreceived from physicians while accompanying theirpartners to a consult. Other fathers also added the im-portance of physicians in encouraging them to quitsmoking, but the majority acknowledged that they didnot seek or get help from health professionals.All the fathers had made more than one quit attempt,and at the time of the interviews 12 fathers were smokefree. Participants, including the current smokers, expresseddifficulty in quitting because of the habit of smoking, butdownplayed the usefulness of cessation aids. They also hadlittle interest in counseling or telephone services even ifthe services were free. A 28-year-old father who had quitsmoking for about three months pointed out that Chinesemen do not use smoking cessation services: “Canadianslike to use the hotline but it doesn’t mean it is useful.Sometimes they just like to call to chat. Very seldomChinese call it”. He attributed this indifference to cessa-tion services to personal qualities of self-reliance andindependence, lofty attributes cultivated in Chineseculture:Canadian governments can help its people to solveproblems. The governments in China don’t care aboutyou; so who you can rely on if you don’t rely onyourself? Chinese people rely on themselves or theirclose friends when they come across problems. Nomatter how hard their life is, Chinese tend not to relyon governments.The fathers insisted that a successful quit requireddecisiveness and willpower on their part, and that if aman “wanted to quit” nothing more was needed. Theyframed external aids, physical or psychological, as strat-egies that Caucasian men relied on. In this way, theChinese men positioned themselves as more autono-mous and stronger willed than Canadian men.Smoking was also perceived as a personal hobby andthe Chinese fathers tended not to share their smokingand quitting experiences in fear that their privacy wouldbe violated. A 33-year-old father who had quit smokingexpressed concern about losing face if he went to cessa-tion services:There are not a lot of Chinese here so everyone knowseach other. Your privacy will lessen within the smallgroup and your friends and relatives may know of that.You know, we Chinese care about our face. We do notwant to give other people any bad image about us.Saving face and the protection of privacy in this con-text can also be interpreted as a means of maintaining apublic image of masculine strength, invulnerability, andbeing in control. Also evident in the commentaries isthe existence of masculine hierarchies, whereby theparticipants jockeyed for position among Chinese immi-grants, making assertions about Eastern and Westernmen’s legitimate purchase on hegemonic masculinity.DiscussionThe findings from the current study provide importantempirical and theory based insights into Chinese Canadianfathers’ smoking. The facilitators and barriers to partici-pants’ smoking reflect findings drawn from previousstudies chronicling how immigrants from cultures thatnormalize smoking tend to reduce their smoking afterimmigrating to countries that strive to be smoke free[41]. However, ever present in the current findings arecomplex connections underpinning Chinese Canadianfathers’ concessions around smoking post-immigration.For example, adherence to traditional Chinese values offamilism and collectivism appear to cultivate effortstoward smoking cessation within the Canadian context.At the same time, Western norms around reducingsmoking to benefit one’s health as well as aid familywell-being also emerged as influencing men’s efforts tobe smoke free.Sociologists report that Chinese individuals tend topursue the collective interests of the family rather thanindividual interests [42]. In the context of the currentstudy, protecting children from the harms of tobaccosmoke is normative, reflecting Chinese cultural ideals offamilism. Although not overtly expressed, many partici-pants suggested feeling pleased, and perhaps lucky thatthey were able to conform to Canadian cultural idealsabout maintaining a smoke-free home. Reflected in thisbicultural positioning is evidence of both acculturationand a keen sense of traditional Chinese values, includingthe need to save face in the host country. In terms ofmasculinities, this willingness to conform to Canadianvalues and tobacco use norms might indicate ChineseCanadian immigrant men harbored little interest inrebellion or protesting against dominant cultural idealsand structures by smoking in prohibited ways and/orplaces. In contrast, Chinese Canadian fathers self-sacrificedin a range of ways (e.g., underemployment, financialburden, isolation, etc.) to make good on the patriarchalpromise of providing a better life for their families. Itcan also be reasonably argued that smoking in Canadawas less focussed on being with and/or connecting withother men. In this respect there were likely fewer mas-culine pressures for men to smoke in Canada, especiallygiven the absence of ritual cigarette sharing among men inthe West. Despite upholding familism, Chinese fatherscould be providers rather than involved caregivers due tothe traditional cultural divisions of domestic and familyMao et al. BMC Public Health  (2015) 15:286 Page 8 of 10care labor. An important change for the Chinese Canadianfathers was the increased caring responsibilities embodiedas fathering norms in Canada. The direct childcare normsand expectations enhanced the fathers’ identity as pro-tector of their children. Ultimately, this change contrib-uted to their smoking reductions, because the more timefathers spent with their children, the less likely they wereto smoke, a finding that is in line with other studies[33,43]. From the perspective of the Chinese Canadianfathers, their introduction to and the permission to bemore involved in fathering– when taken up - wasframed as a masculine virtue reflecting some Chinese andCanadian ideals. In this respect, being an engaged fatherreflected their alignments to a range of bicultural norms.Masculine ideals of self-control and autonomy areregarded as important influences in men’s attempts toquit smoking [21,32,33]. The majority of men quit smok-ing without aids in all cultures [44]; however, more than90% of Chinese smokers quit unaided [45], compared totwo-thirds to three-quarters of smokers elsewhere [44].Our study showed that Chinese men’s self-reliance inquitting smoking was politically motivated and articulatedwithin Chinese cultures, propelling a spirit of independ-ence and autonomy. Masculine ideals are multifaceted andinfluence men’s smoking locally, regionally and globally[38]. So, while direct fathering and protector and providerroles prompted the fathers to abstain in the local contextmany fathers did not regard their continued (light)smoking away from their family as diminishing theireffectiveness as a father. In this way, the Chinese fatherswho continued smoking did so outside the role offathering, within regional and global arenas and contextswhere smoking was accepted – and affirmed. Accordingto the fathers, they believed smoking would not be harm-ful if they smoked in a controlled manner. This findingraises potential challenges for future smoking cessationinterventions, because the current slogan to motivateCanadian fathers to quit smoking, “Don’t let your chil-dren be a target. Make your home smoke-free”, [46],while effective in the local context, might have littleweight in other contexts.Implications for smoking cessation interventionsThere are very few smoking cessation interventions inNorth America targeting Chinese immigrant men ormore specifically fathers. Instead, tobacco control ap-proaches have tended to be gender and culture neutral[47,48]. The current study findings confirm previous re-search indicating many Chinese immigrants had eitherquit smoking or substantially reduced their smoking[8-11]. This trend would be substantially advanced withtargeted interventions.Central to supporting these cessation efforts will beeffective education to correct misinformation about thehealth risks of light smoking [49]. This is important be-cause, over the last 10 years, the prevalence of lightsmoking subgroups in the USA have steadily increased,and now account for more than 20% of individuals whosmoke [49]. Light smokers may be more receptive thanpreviously believed to messaging about the risks ofcontinued smoking [49]. The current study reveals twotime points when Chinese Canadian men re-think theirsmoking: immediately after arrival in Canada, andduring their partners’ pregnancies. Relevant health mes-sages may be easily taken up by the Chinese immigrantsmokers if they coincide with the smokers’ life events.Printed or online health messages can be developed inaccord with the masculine ideals of Chinese Canadianmen. Oliffe et al. [32] suggested three principals toguide the development of the health messages targetingmen: 1) using positive messaging to promote changewithout amplifying stigma, guilt, shame, and blame; 2)fostering connections between masculine ideals (e.g.,strength, decisiveness, resilience, autonomy) and beingsmoke-free; and 3) privileging the testimonials of poten-tial end-users (e.g., fathers who smoke and want toquit). These principles might reasonably guide culturesensitive approaches that appeal to specific masculinenorms such as familism and collectivism among ChineseCanadian men.The findings from the current study are limited in thatthey cannot be reliably generalized to large populationsof Chinese men. Although the findings indicate that thehigh cost of cigarettes, comprehensive smoking bans inpublic places and the denormalization of tobacco use ingeneral influenced Canadian Chinese fathers to quit smok-ing, some men did not quit. There is a need for furtherresearch with diverse groups of Chinese men to extendour understanding of the influence gender-related factorsand other social determinants on smoking patterns to in-form the development of tailored cessation interventions.ConclusionsThis description of Chinese immigrant fathers’ experiencesrelated to tobacco reduction and cessation in Canada addsto the growing knowledge regarding gender-related factorsinfluencing men’s smoking. Chinese immigrant men whosmoke tend to quit or reduce their smoking prompted byan interplay of bi-cultural factors related to immigration,being a new father, and desires to conform to tobacconorms and fathering roles in the host country. TraditionalChinese familism complemented Canadian norms relatedto protecting children from secondhand smoke, and con-tributed to the men becoming smoke free or reducing theirlevels of smoking. Increased child care responsibilities anddecreased networking with male friends and colleaguesin Canada resulted in less time and fewer settings thatfacilitated tobacco use. In contrast, for those who continuedMao et al. BMC Public Health  (2015) 15:286 Page 9 of 10to smoke at reduced levels, tobacco was perceived as areward for fulfilling masculine provider roles underdifficult circumstances. The findings have implicationsfor the development of future smoking cessation inter-ventions targeting Chinese Canadian immigrant smokersas well as smokers in China.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsAM, JB and JO conceived and designed the study. AM collected the data. AM,JB, JO and GS analyzed the data and were involved in manuscript writing. MKassisted with interpretation of the data and writing the manuscript. All authorsread and approved the final manuscript.AcknowledgementsThis research and article was made possible by the Canadian Institutes ofHealth Research (Grant #62R43745). In addition, Dr. Mao was supported by apostdoctoral fellowship award from the Psychosocial Oncology ResearchTraining (PORT) program.Author details1Kiang Wu Nursing College of Macau, Est. Repouso No.35, R/C, Macau, China.2School of Nursing and Institute for Healthy Living and Chronic DiseasePrevention, University of British Columbia, 3333 University Way, Kelowna, BC,Canada. 3Faculty of Health Sciences, Australian Catholic University,Melbourne, VIC, Australia. 4School of Nursing, University of British Columbia,302 6190 Agronomy Rd, Vancouver, BC, Canada. 5Institute for Healthy Livingand Chronic Disease Prevention, University of British Columbia, 3333University Way, Kelowna, BC, Canada.Received: 12 November 2014 Accepted: 16 March 2015References1. Li Q, Hsia J, Yang G. Prevalence of smoking in China in 2010. N Engl J Med.2011;364:2469–70.2. Ding D, Hovell MF. Cigarettes, social reinforcement, and culture: acommentary on “Tobacco as a social currency: cigarette gifting and sharingin China”. Nicotine Tob Res. 2012;14(3):255–7.3. Mao A, Bristow K, Robinson J. 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[Epub ahead of print] doi:10.1136/tobaccocontrol-2013-051348]Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionMao et al. BMC Public Health  (2015) 15:286 Page 10 of 10Submit your manuscript at www.biomedcentral.com/submit

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