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Chinese immigrant men smokers’ sources of cigarettes in Canada: A qualitative study Mao, Aimei; Bottorff, Joan L; Oliffe, John Lindsay; Sarbit, Gayl; Kelly, Mary T Mar 21, 2017

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RESEARCH Open AccessChinese immigrant men smokers’ sourcesof cigarettes in Canada: A qualitative studyAimei Mao1*, Joan L. Bottorff2,3, John L. Oliffe4, Gayl Sarbit2 and Mary T. Kelly2AbstractBackground: Immigrants often experience economic hardship in their host country and tend to belong to economicallydisadvantaged groups. Individuals of lower socioeconomic status tend to be more sensitive to cigarette price changes.This study explores the cigarette purchasing patterns among Chinese Canadian male immigrants.Methods: Semi-structured in-depth interviews were conducted with 22 Chinese Canadian immigrants whowere smoking or had quit smoking in the last five years.Results: Because of financial pressures experienced by participants, the high price of Canadian cigarettes posed asignificant challenge to their continued smoking. While some immigrants bought fully-taxed cigarettes from licensedretailers, more often they sought low-cost cigarettes from a variety of sources. The two most important sources werecigarettes imported during travels to China and online purchases of Chinese cigarettes. The cigarettes obtainedthrough online transactions were imported by smoking or non-smoking Chinese immigrants and visitors, suggestingthe Chinese community were involved or complicit in sustaining this form of purchasing behavior. Other less commonsources included Canada-USA cross border purchasing, roll your-own pouch tobacco, and buying cigarettes availableon First Nations reserves.Conclusions: Chinese Canadian immigrant men used various means to obtain cheap cigarettes. Future research studiescould explore more detailed features of access to expose gaps in policy and improve tobacco regulatory frameworks.Keywords: Chinese immigrants, Canada, Qualitative study, Sources of cigarettesBackgroundTobacco use is the most important preventable cause ofmorbidity around the world, and is associated withnearly six million deaths per year [1]. Smoking is dispro-portionately represented among people from lowersocial economic status (SES) [2–4]. People in lowerincome groups and with less education are more likelyto buy cheaper cigarette brands [5–7]. As a result, thesegroups are more sensitive to increased taxes on tobaccoproducts and more often attempt to access cheapcigarettes through unconventional channels, such aspurchasing cigarettes in duty-free shops, buying traf-ficked untaxed cigarettes, and hand rolling tobaccoleaves [8–10]. It is believed that the illicit tobaccomarket may account for as much as one in every 10cigarettes consumed globally [1].China has the largest number of smokers in the world -one in three smokers in the world is Chinese [11]. Smok-ing in China is predominantly a male behavior. More thanhalf of Chinese adult men smoke while less than 3% ofChinese women smoke [11]. China is also the largestproducer of cigarettes. Tobacco use in China is influencedby wide variation in cigarette prices, ranging from lessthan 10 RMB (Renminbi, Chinese dollars) to more than1000 RMB a pack (20 cigarettes/pack and 10 packs/car-ton), thereby accommodating smokers from all incomelevels. Although the wholesale tax on cigarettes in Chinahas increased from 5 to 11%, it still lags far behind theWHO (World Health Organization) recommended levelof 67–80% [8] and makes cigarettes relatively cheap formost smokers.Studies indicate that immigrants to industrializedcountries often experience difficulty in finding suitableemployment and usually obtain lower salaries than othercitizens [12–14]. This difficulty is usually more apparent* Correspondence: maoaimei@kwnc.edu.mo1Kiang Wu Nursing College of Macau, Est. Repouso No.35, R/C, Macau, ChinaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Mao et al. Tobacco Induced Diseases  (2017) 15:18 DOI 10.1186/s12971-017-0123-1among new immigrants than long-term immigrants, butnonetheless immigrants often belong to social andeconomically disadvantaged groups [7, 15–17]. Inversely,new immigrants from cultures with high smoking preva-lence also smoke more than older immigrants and main-stream populations before they adapt their smokingpatterns to the norms of the new environment [18].Chinese male smokers may experience challenges totheir continued smoking after they immigrate to devel-oped countries, given the economic difficulties theyencounter, combined with the probability of higherpriced cigarettes in the host country. Studies on Chineseimmigrants’ smoking behaviors are limited. Severalstudies, mainly from the United States, report thatChinese immigrant smokers reduce their smoking morethan other subpopulations [19–22]. Despite reductions,a substantial proportion of Chinese immigrants continueto smoke [23]. Poorly understood are the influences ofdifferent tobacco markets in the host countries onChinese immigrants’ smoking.This article is drawn from a qualitative study focusedon the smoking behaviors of Chinese Canadian immi-grant fathers who smoke [24, 25]. As part of the study,participant’s access to cigarettes was investigated andthese data were analyzed for the current article. Canadahas a history of introducing comprehensive tobaccocontrol measures and has continued to increase taxationon tobacco products. As a result, Canada has one of thelowest smoking rates in the world, with a general smok-ing prevalence of 14.6% (16.0% among men and 13.3%among women) [26].From 2006 to 2015, 290,912 new permanent residentsfrom China landed in Canada, and the Chinese comprisethe second largest foreign-born group in Canada [27]. It isimportant to explore how cigarettes are accessed toinform tobacco control policy and the development of in-terventions to reduce smoking among Chinese immigrants.MethodsParticipant recruitmentA qualitative descriptive approach as described bySandowski [28, 29] was used focusing on gaining a fullunderstanding of behaviors and practices from partici-pant perspectives. Bilingual recruitment advertisementswere distributed to Chinese organizations in the lowermainland of British Columbia, Canada and posted onChinese online forums. The forums were publicallyaccessible and hosted on websites in Canada withChinese language to serve Chinese Canadian immi-grants. Potential participants were invited to contact theresearch team by telephone or email and then screenedfor eligibility.Criteria for eligibility included the following: 1) self-identified as a male Chinese immigrant or ChineseCanadian; 2) currently smoked or quit smoking in thepast five years; and 3) lived in Canada for at least half ayear. As per the original project, participants werefathers who were expecting a child or had a child underthe age of five years. Twenty-two men, recruited throughthe Chinese forums (n = 21) or through the Chineseorganizations (n = 1), met the study criteria and providedinformed consent. All participants were first-generationimmigrants; two migrated to Canada with their parentsbefore 18 years of age, and the other 20 migrated afterage 18. They had lived in Canada for an average of 8.7 ±6.4 years (range = 0.5 to 22 years), 19 of the men for lessthan 15 years. Characteristics of the sample are shownin Table 1.All 22 participants were smoking at the time theymigrated to Canada. At the time of interview, 12 par-ticipants had quit smoking (defined as having stoppedsmoking for at least one week) and the other ten hadsubstantially reduced their smoking. Two of the ex-smokers quit their smoking around five years agowhile the other ten quit within the last three years.Among the current smokers, three smoked 10–18Table 1 Demographics and smoking patterns of the Chineseimmigrants who smokedCategory Number of participantsEducationElementary school and below 0Junior/middle school 1High school 0Non-university (collage, vocational,technical, trade etc.)3Bachelor’s degree 13Master’s degree or over 5OccupationClerical/Administrative 5Construction/Manual Labor 7Technical/Skilled/Professional/Trade 7Unemployed (Disabled, Student) 3Marital statusMarried 21Divorced 1Amount Smoked≤ 10/day 710-20/day 3> 20/day 0Quit Smoking 12Age (years old) 38 ± 5.0 (28 to 46)Years in Canada 8.7 ± 6.4 (0.5 to 22)Mao et al. Tobacco Induced Diseases  (2017) 15:18 Page 2 of 8cigarettes per day (CPD) and the other seven smokedfewer than 10 CPD.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 the researchers’ ability to reachChinese immigrants from multiple regions. Moreimportantly, telephone interviewing afforded participantsmore anonymity than face to face interviewing [30]. Theinterviews focused on changes in the participants’ smok-ing since immigration, exploring participants’ access tocigarettes. Interview questions included: “How has yourlife changed since you came to Canada?”; “How has yoursmoking changed since you came to Canada?” “What doyou think of the differences in smoking practicesbetween Canada and China?” and “How do you get yourcigarettes in Canada?”Probes and follow-up questions were used to encour-age the participants to provide more information relatedto the purposes of the study. The interviews wereconducted by the first author, a bilingual researcher(AM), and lasted from between 30 and 90 min. The datafrom the 22 interviews were rich, covering differentaspects of the participants’ smoking experiences. Thechanged smoking behaviors and their related contribu-tors, and the participants’ perception on the smokingdifference between China and Canada have been pre-sented in somewhere else [24, 25, 31]. Probes andfollow-up questions were also used to encourage theparticipants to share information on whether and howthey accessed cigarettes via unconventional ways, suchas online purchases, duty-free purchases, and cross-border shopping, etc. The participants clearly relatedtheir accessing cigarettes to their economic situationand supplemented information concerning theiremployments to the question “How has your lifechanged since you came to Canada?” These data setfoundation for this article.Data analysisThe participants, who were all Chinese immigrantscurrently smoking or having once smoked, were codedas “CS” (Chinese smoker), and numbered sequentially asthey entered the study. All interviews were digitallyrecorded, translated into English and transcribed. Abilingual research assistant with Chinese and Englishproficiency translated the interviews and the translationswere checked by the bilingual researcher (AM). Theteam used qualitative content analysis [31] wherein theprimary aim was to describe the phenomena. Thecategories and names were initially derived from databased on close readings of the first three interviews.These emergent categories were organized and groupedinto meaningful clusters and definitions developed toform a coding framework that was used to systematicallycode the interview data. The qualitative data manage-ment program NVivo8 was used to code and retrievedata. Data coded to each of the categories were reviewedin detail by comparing and contrasting data from allparticipants. Attention was paid to identifying patternsin participants’ perspectives about accessing cigarettesand illustrative quotes were identified.ResultsThe men quit or reduced their smoking due to variousreasons, as ‘Concern over impacts of smoking onchildren’s health’, ‘Different smoking environmentbetween China and Canada’, and ‘economic concern’being cited as the most important facilitators. Thesefacilitators have been presented elsewhere [24]. Although‘economic concern’ was cited as an independent facilita-tor, this factor was, in fact, interplayed with other factorsto produce complicated influence on the men’s changedsmoking, which will be described in detail below.Access to cigarettes and smoking patterns followingimmigration were directly influenced by challenges asso-ciated with immigration, the landscape of tobaccocontrol in Canada and the responsibilities associatedwith fatherhood. The majority (20) of the 22 participantsmigrated to Canada in adulthood, and they describedsignificant life changes after immigration. In most of theparticipants’ families, the wives were either full-timecaregivers or worked part-time, because they could notafford paid childcare services. The fathers (participants)were expected to act as the primary breadwinners forthe family. Despite being well educated and/or havinghad good jobs in China, the men had difficulty findingsuitable jobs after they arrived in Canada. Several partic-ipants attended Canadian universities to pursue furthercareer training. Others were underemployed, and workedas laborers or in unskilled jobs with poor salaries. Severalparticipants worked two part-time jobs, mainly in Chineserestaurants or supermarkets.All participants, both current smokers and ex-smokers,talked about the high price of cigarettes in Canada and inrelation to their financial situation. They complained thatthe cigarettes in Canada were much more expensive thanthose in China. Unlike China, where a wide price range incigarettes facilitates smoking for individuals from differenteconomic conditions, Canadian cigarettes were universallyexpensive with no discounted or cheaper brands. Severalparticipants mentioned going to licensed retailers, such asgas stations, supermarkets, or convenient stores, to buyfull-taxed cigarettes, but more often they sought cheapersources to afford their smoking (Table 2). The followingMao et al. Tobacco Induced Diseases  (2017) 15:18 Page 3 of 8section details the avenues participants found to purchasecheap cigarettes.Bringing in cigarettes from ChinaAlmost all the participants described obtaining Chinesecigarettes directly from China. They did this for tworeasons. The most prominent reason was, of course, thelower price of Chinese cigarettes. The other reason wasthat participants preferred the taste of Chinesecigarettes. A participant (CS2) who had lived in Canadafor three years and had quit smoking for four monthsexplained the taste difference between Chinese andCanadian cigarettes, “Chinese cigarettes are toasted,while western cigarettes are mixed. The tastes are quitedifferent.” (CS2). The mixed cigarettes were those madeof toasted and sun dried tobacco. Some participants,especially those who had lived in Canada for less thantwo years, complained about the “unpleasant” taste ofCanadian cigarettes.The participants, therefore, sought out Chinesecigarettes. Since Canadian customs allowed adultsentering Canada to bring in one carton of cigarettes,participants commonly asked their friends and familymembers, whether they were smokers or not, to bringcigarettes whenever they visited Canada. One participantstated: “When I first came to Canada… I brought acouple of cartons of Chinese cigarettes. Later my friendsbrought 5 or 6 for me when they came here fromChina.”(CS2, ex-smoker). With the increasing number ofChinese individuals migrating to Canada and greaternumbers of Chinese visitors entering Canada every year,global travel patterns between China and Canada havebecome an important means of supply for cheapcigarettes. A current smoker (CS14) who smoked 2–3CPD and had lived in Canada for seven years said “Mysource of Chinese cigarette never stops.”In China, smoking is embedded into men’s social lifeand smoking premier brands of cigarettes is a culturalsignifier of status; however, once in Canada the partici-pants no longer felt compelled to share and giftcigarettes with other men. A participant (CS12) who hadquit smoking three years previous, described howChinese immigrants usually did not buy the premierbrands, but felt the ordinary Chinese cigarettes now mettheir needs, “The expensive cigarettes in China, likeZhonghua [the name of a premier brand of Chinesecigarettes] is not fancy here because many Chinese don’tsmoke that brand. The ordinary brands of 5 or 10 RMB[1Canadian dollar =0.98U.S. dollar =6.04 Chinese ren-minbi in 2013] a pack are popular.” Participants whohad once purchased premier brands to impress theirbusiness partners, superiors, and colleagues, thoughtthey spent less on smoking after arriving in Canada.Also, because there was no culture of gifting tobaccoin Canada, the participants could more easily estimatehow long their cigarette stock would last in schedul-ing a fresh supply.Online purchaseThe participants said they used the Internet to find on-line sources for Chinese cigarettes. With dozens ofChinese websites available in Canada, the participantsnever found difficulty in seeking out online sellers.Online sales were offered by both smokers and non-smokers and presented significant savings for regularsmokers. A participant who had quit smoking one andhalf years ago said:Chinese cigarettes are much cheaper than Canadiancigarettes. I can tell you if Caucasians are able to buycigarettes from China, they would buy them too. It isa competition. One pack of cigarette in Canada costs8 or 9 dollars but it only costs 3 or 4 dollars for thesame brand in China; it is almost half price. If youdo the calculation, how much money can you save ina year if you save 30 dollars every month? (CS8)Because of Canadian customs laws, the onlinecigarette sales are for personal use only. The partici-pants, however, had noticed how the online sales wereexpanding rapidly. “The online market is indeed a bigmarket, and a mature market. If you surf the XX [oneChinese website in Canada, name redacted], you will findthat many Chinese are selling cigarettes there.” (CS6,current smoker)The only concern participants expressed about onlinecigarette sales was the possibility of buying “fake”cigarettes. The Chinese immigrants were adamant thatthere were many fake cigarettes in the marketplace inChina; therefore, it was possible that fake cigaretteswould find their way to online markets. It is not surpris-ing that the possibility of buying fake cigarettesprevented several participants from buying online. Aparticipant (CS20) who currently smoked 1–3 CPD said,“I don’t buy cigarettes shown on those Chinese websites,because my friends told me there are fake.” Therefore,the online sales often involved face-to-face contactTable 2 The price-reduction sources cigarettes mentioned bythe participantsThe sources NBringing in cigarettes from China 20Online purchase 11Buying cigarettes in duty-free shops 8Cross US-Canada border purchase 7Roll-your-own cigarettes 2Purchase in Indian’ reservations 1Mao et al. Tobacco Induced Diseases  (2017) 15:18 Page 4 of 8between buyers and sellers after initial contact had beenestablished over the Internet. When personally meetinga seller, the buyer would have a chance to check whetherthe cigarettes were fake or not. A participant whocurrently smoked (CS 17) said he sometimes boughtcigarettes online, and described his way of assessing thepossibility of fake cigarettes: “After we met he showed methe carton he was selling. I checked the packing andsmelled the cigarettes. He encouraged me to try one ofthe cigarettes.”Despite being referred to as an “online” purchase bythe participants, the Chinese websites actually func-tioned as a method of connecting buyers and sellers inperson, because there was no payment system on thewebsites. Payment took place offline, face-to-face, asCS17, a current smoker, detailed about the purchasingprocess: “You go to the web, find someone near yourplace selling cigarettes. You make a phone call. Then youdecide to meet each other at some time in somewhere.You then do the trade face to face.”As importing cigarettes from China for personal usewas legal, the online trade was also perceived by partici-pants to be legal. A participant who had quit smokingfor four months (CS2) but had previously accessedcigarettes using the online system, defended hispurchase, saying: “It is usually legal, unless you buycigarette packs in a large number from someone.” So itwas possible that both sellers and buyers sometimesdivided larger sales into smaller chunks to avoid beinglabeled as “illegal.”Buying cigarettes in duty-free shopsDuty-free shops were a must-go place to shop for almostall the participants when they travelled across borders.These shops are the only Canadian retail outlets that sellChinese cigarettes, and the cigarettes in these shops areeven cheaper than those in Chinese markets. A partici-pant (CS12) who had quit smoking for three years spokeof the price difference, “I bought a carton of Zhonghua[a Chinese cigarette brand] in a duty-free shop in theUS. It was a little more than 40USD, cheaper than inChina.” Interestingly most participants, including thosewho had quit smoking, purchased duty-free cigarettesnot for themselves but for other people, because thebrands of cigarettes in the duty-free shops were oftenthe premier ones. Also, the participants preferred thepremier brands from duty-free shops because thesebrands were believed to be genuine; whereas, peoplemight get fake brands in the markets in China. In fact,cigarettes in the duty-free shops were in such demandthat it was often difficult for the participants to obtainthem. One participant (CS12) remarked that although hehad quit smoking, he still routinely went to the duty-freeshops to buy cigarettes and other items for his familyand friends each time he crossed the border. Accordingto him, it was hard to get the premier cigarettes in theairports duty-free shops, but he always tried;You are not able to get them. They are sold outquickly. I guess it is because there are too many fakebrands in Chinese markets. My friends who work inthe airport told me that all the Zhonghua [a premiercigarette brand] would be bought up by the clerksworking there as soon as Zhonghua arrived. (CS12,ex-smoker)Regardless of smoking status, most participants, aswell as their friends and family members, always stoppedin duty-free shops to purchase cigarettes for gifts orpersonal use. The cigarettes purchased in duty-freeshops here went in two directions: inside Canada forimmigrant smokers’ use and outside Canada to satisfythe Chinese gifting culture and international smokers’preference for specific brands.US-Canada cross border purchasesSome participants described their purchase of cigarettesfrom US markets. They mentioned how cigarettes werecheaper in the US: “My friends brought me Camel andDavidoff from the US. These are American brands. Thereare the same brands here in Canada. But they arecheaper in the US.”(CS14, current smoker) “One pack ofMarlboro costs 11 dollars in Canada; if I go to the US Ionly spend 7 dollars for a pack.” (CS13, ex-smoker)Despite cheaper cigarettes, US-Canada cross borderpurchases were practiced by only a few participants dueto customs laws. One participant explained, “There is aregulation that you need to stay in the US for at least48 h for being able to bring in a carton of cigarettes.”(CS13, ex-smoker). As a result, the participants whosmoked asked other people to buy cigarettes for themwhenever they visited the US. Two participants wholived near the US border stated that US cigarettes weretheir primary source of cigarettes. They frequented theUS for cheaper cigarettes and other daily necessities.One participant who had lived in Canada for 11 yearsand had quit smoking just two months previous due tohealth concerns for his two young children, joked thathe crossed the border so often that he was moreAmerican than Canadian;I live in Surrey and it takes me only 20 min to drive tothe Costco in the US. All the goods in the USsupermarkets are cheaper than those in Canada. OnceI run out of cigarettes I go there to buy. In daily life Ispend USD not CAD [Canadian dollar]. I feel myselfsemi-American, perhaps more American than Canadian.[laughed] (CS22)Mao et al. Tobacco Induced Diseases  (2017) 15:18 Page 5 of 8Purchasing from First NationsA participant from Quebec who smoked 1–3 CPD talkedabout his experiences with purchasing cigarettes onIndian reservations: “I don’t go online purchase. I usuallygo to the Indian’s reservations to buy cigarettes becausethey are cheaper there.” He made these purchases withthe knowledge that it was illegal for First NationsCanadians to sell cigarettes, “The cigarettes that Indiansmake are very cheap because there’s no tax on them. Butthey are not licensed to sell. The law regulated theircigarette sales for only their own use.” He was, however,not concerned about an illegal purchase because he hadheard many Canadians who purchased cigarettes in thisway were never bothered by the police.Roll-your-own cigarettesA few participants resorted to purchasing loose tobaccoto roll their own cigarettes to reduce the cost of smok-ing. One participant admitted to growing tobacco in hisapartment, and vividly described the way he cared forthe plant. According to him, rolling the tobacco leavesfrom his own plants had distinct benefits: “It is obviouslycheap to smoke this way. The tobacco leaves are veryclean because these are the ones you have grown, right?”He was also confident that his roll-your-own methodwas legal. “You know the drugs, weed. Many people plantthem at home too. That is illegal. But planting tobaccoleaf is legal. The farmers in China usually plant tobaccofor their own use. It’s like the same.” Although heclaimed that many other people around him did thesame, none of the other Chinese participants mentionedhaving planted tobacco or even having heard of it. Theywere not sure about legality of this practice butsuggested that people who had done the same might nottell outsiders if they perceived the practice as illegal.DiscussionThis is the first study to explore how Chinese Canadianimmigrant men who smoke access cigarettes. It providesvaluable knowledge about the ways in which Chineseimmigrants circumvent fully taxed cigarettes in Canadato continue their smoking.This study supports the findings from previousresearch showing that although higher priced tobaccoproducts may prompt low SES smokers to reduce orquit smoking, higher prices trigger the search for low ornon-taxed options [8–10, 32]. The Chinese immigrantparticipants in this study resorted to some novelmethods to satisfy their search for cheap cigarettes, apurchasing pattern that somehow deviates from thetobacco purchasing patterns of the mainstream popula-tion. A recent Canadian survey reported that smokers inCanada buy their cigarettes in the following ways: some90% from a small grocery or convenience store or gasstation, 6.5% from friend/family/someone else, 2.4%from First Nations reserves, and 2,2% from othersources [26]. While the participants, particularly thenewer immigrants, might not be familiar with some ofthese purchasing patterns, they found unique means tobuy cheap cigarettes by making use of their linkages toChina. Strikingly, these Chinese immigrants were able tocarry on purchasing cheap cigarettes on a long termbasis. By accessing the cheap Chinese cigarettes, theChinese immigrants were not only able to stick to theirpreferred cigarette tastes, but more importantly, affordedtheir smoking outside China.Studies have found that people with high SES tend tobuy overseas cigarettes simply because they traveloverseas more often than those of lower SES [10]. Ourstudy, however, identified how, despite their SESconstraints, the Chinese immigrants also accessed cheapoverseas cigarettes based on their international connec-tions. The customs restrictions at Canadian borders didnot influence the participants’ stock of Chinesecigarettes. Increased international travel among theChinese participants’ extended family and friends facili-tated their access to Chinese cigarettes across borders.The practice of accessing Chinese cigarettes has becomean established behavior that involved the immigrantsand their wider social networks. In this way, global travelpatterns have outstripped the capacity for national andlocal regulatory frameworks to restrict tobacco. It ispossible that within the context of international traveland international immigration patterns, tobacco pur-chasing patterns have reverted to patterns not unlikemarijuana and other black market substances.The influx of Chinese cigarettes brought across bor-ders by Chinese immigrants and visitors has led to theonline sales of Chinese cigarettes. There is a good possi-bility that the online market will grow with the inflow ofmore Chinese immigrants and visitors. It may developbeyond Chinese communities and attract mainstreamsmokers in Canada due to the extremely low price ofChinese cigarettes in this unregulated market. Theparticipants expressed concerns about fake cigaretteswith the surge of the online market and their concernsare justified. Produced in illegal cigarette factories inChina, fake cigarettes in the form of “knock-off”Marlboros and other popular brands, are sold around theworld. Lab tests indicate that these fake cigarettes containhigher levels of nicotine and toxic chemicals than brand-name cigarettes as well as contaminants [33].Still, this demand for low-priced cigarettes willcontinue to fuel the presence of Chinese manufacturedfake cigarettes available for online purchase. Otherresearchers have argued that the purchase of cheap on-line cigarettes is more likely to be used by people ofhigher SES, because it requires specific equipment andMao et al. Tobacco Induced Diseases  (2017) 15:18 Page 6 of 8skills [9, 34]. However, as computers, including mobilesand wi-fi internet access is quickly becoming a norm ofdaily life for people from all backgrounds, online trans-actions in cigarettes will likely continue to grow.Our study reveals that in addition to price-reduction,duty-free shop purchases reinforced the Chinese cultureof gifting tobacco, which further enhanced the shoppingmotivations among the Chinese immigrants and theirvisitors. Other means of price-reduction purchases, suchas purchasing cigarettes from neighboring USA, andpurchasing cigarettes on First Nations reserves, were lesslikely to be used by participants in this study. This mightbe due to Chinese immigrants’ unfamiliarity with thesesources or perhaps that their current sources had alreadymet their needs. Still, there is a possibility that Chineseimmigrants may explore other means of access thelonger they live in Canada or as their smoking pat-terns change.It should be pointed out that the flowing direction ofcigarettes across borders may change with the change ofexchange rates of currencies, which seem to havebecome more fluctuated in the past years. During thetime the study was conducted in 2013, the value ofCanadian dollar was also the same of USA dollar.The Canadian dollar has ever sense devalued com-pared to US dollar. The current US-Canada exchangerate is very unfavorable to Canadians and may meanthat “border crossing” for cigarettes from USA toCanada is no longer attractive.LimitationsAs with all qualitative research, caution is needed ingeneralizing the findings from this study to Chinese im-migrants who smoke, not only because of the smallnumber of the participants, but also because of theparticipants being a group of expectant fathers or fathersof young children. Also, the reliance on telephone inter-views might have resulted in participants omittinginformation or communicating in ways that did notreflect the actual situation. For example, some partici-pants might have perceived unconventional access tocigarettes as illegal and may have concealed theiractual experiences.Implications for policies and researchAs international efforts have attempted to curb illegaltrade in tobacco, our study sheds light on how indi-viduals legally obtain cheap cigarettes across bordersand therefore sustain smoking prevalence among theimmigrants. The current measures have not doneenough to control the cross-border flow of cigaretteswhen each and every person travelling can legallycarry cigarettes. A complete ban on tobacco crossingborders may be necessary.Online purchase of cigarettes is a rapidly developingmarket in almost every country, and some nations haveimposed restrictions. For example, in the USA, govern-ments have collaborated with credit card companies tocontrol online tobacco business [35]. The findings of thecurrent study, however, pose new challenges to onlinesales because Chinese immigrants’ online purchases alsoinvolve off-line personal contacts. Monitoring andrestrictions may need to be applied to website advertise-ments of tobacco products, regardless of language.There are suggestions that tax increases should equallyapply to factory-made and roll-your-own cigarettes [32].While the First Nations people continue to offer tax-freesales of tobacco in their communities, there have beencalls to implement taxation of tobacco sold to non-status Indians [8]. Increasing tobacco taxes in neighbor-ing countries with lower cigarette prices has also beensuggested. The European Union has urged to reduceprice differences between the union countries, and toreduce the number of cigarettes or amount of loose leaftobacco that a person can legally import for personalconsumption [10]. However, the findings from our studysuggest that imposing restrictions on the number ofcigarettes that individuals can carry across borders is notlikely to be sufficient to slow or stop the globalmovement of cigarettes. A complete ban on tobacco prod-ucts across borders is necessary. However, it is not clearhow countries could co-ordinate this effort and the extentto which it could stimulate the black market is unknown.ConclusionsThe current study findings support the notion thatprice-reduced sources of cigarettes are popular amongChinese immigrants. It also indicates that the currentcross-border regulations on cigarettes are beingabused. Findings from this study support the WHO’s(2016) calls for policy makers, researchers, and thepublic to work together to curb the illicit trade oftobacco products. Our study is the first to providein-depth knowledge about Chinese Canadian immi-grant men’s access to cheap cigarettes. The findingsof the study may have implications to other immi-grants, because other immigrants may also seek lowprice cigarettes due to their similar social economiccondition to Chinese immigrants. Future researchstudies could explore more detailed features of accessto expose gaps in policy and improve tobacco regula-tory frameworks.AbbreviationsCAD: Canadian dollar; CPD: Cigarettes per day; CS: Chinese smoker;RMB: Renminbi, Chinese dollars; SES: Social economic status; WHO: WorldHealth OrganizationAcknowledgementsNot applicable.Mao et al. Tobacco Induced Diseases  (2017) 15:18 Page 7 of 8FundingThis research study was made possible by the Canadian Institutes of HealthResearch (Grant #62R43745) and a postdoctoral fellowship award from thePsychosocial Oncology Research Training (PORT) program.Availability of data and materialsThe datasets analyzed during the current study are available from thecorresponding author on reasonable request.Authors’ contributionsAM, JB and JO conceived and designed the study. AM collected the data.AM, JB, JO and GS analyzed the data. AM initiated the manuscript draftingand all the other authors involved in revising the manuscript. All authorsread and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Consent for publicationNot applicable.Ethics approval and consent to participateThe study was reviewed and approved by the Behavioural Research EthicsBoard of the University of British Columbia, Okanagan Campus, Canada. Allparticipants provided informed consent and were offered a supermarketvoucher worth CAD $50 to acknowledge their contribution to the study.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Kiang Wu Nursing College of Macau, Est. Repouso No.35, R/C, Macau, China.2Institute for Healthy Living and Chronic Disease Prevention, University ofBritish Columbia, Kelowna, Canada. 3Faculty of Health Sciences, AustralianCatholic University, Melbourne, Australia. 4School of Nursing, University ofBritish Columbia, Vancouver, Canada.Received: 20 July 2016 Accepted: 16 March 2017References1. World Health Organization: Tobacco. http://www.who.int/mediacentre/factsheets/fs339/en. Accessed 12 June 2016.2. US Department of Health and Human Services. The Health Consequencesof Smoking—50 Years of Progress. Rockville, MD: Office of the SurgeonGeneral; 2014.3. 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Ribisl KM, Williams RS, Gizlice Z, Herring AH. Effectiveness of state andfederal government agreements with major credit card and shippingcompanies to block illegal Internet cigarette sales. PLoS One. 2011;6:e16754.Mao et al. Tobacco Induced Diseases  (2017) 15:18 Page 8 of 8


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