Mao et al. Tobacco Induced Diseases (2017) 15:18 DOI 10.1186/s12971-017-0123-1 RESEARCH Open Access Chinese immigrant men smokers’ sources of cigarettes in Canada: A qualitative study Aimei Mao1*, Joan L. Bottorff2,3, John L. Oliffe4, Gayl Sarbit2 and Mary T. Kelly2 Abstract Background: Immigrants often experience economic hardship in their host country and tend to belong to economically disadvantaged 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 who were 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 a significant challenge to their continued smoking. While some immigrants bought fully-taxed cigarettes from licensed retailers, more often they sought low-cost cigarettes from a variety of sources. The two most important sources were cigarettes imported during travels to China and online purchases of Chinese cigarettes. The cigarettes obtained through online transactions were imported by smoking or non-smoking Chinese immigrants and visitors, suggesting the Chinese community were involved or complicit in sustaining this form of purchasing behavior. Other less common sources included Canada-USA cross border purchasing, roll your-own pouch tobacco, and buying cigarettes available on First Nations reserves. Conclusions: Chinese Canadian immigrant men used various means to obtain cheap cigarettes. Future research studies could explore more detailed features of access to expose gaps in policy and improve tobacco regulatory frameworks. Keywords: Chinese immigrants, Canada, Qualitative study, Sources of cigarettes Background China has the largest number of smokers in the world - Tobacco use is the most important preventable cause of one in three smokers in the world is Chinese [11]. Smok- morbidity around the world, and is associated with ing in China is predominantly a male behavior. More than nearly six million deaths per year [1]. Smoking is dispro- half of Chinese adult men smoke while less than 3% of portionately represented among people from lower Chinese women smoke [11]. China is also the largest social economic status (SES) [2–4]. People in lower producer of cigarettes. Tobacco use in China is influenced income groups and with less education are more likely by wide variation in cigarette prices, ranging from less to buy cheaper cigarette brands [5–7]. As a result, these than 10 RMB (Renminbi, Chinese dollars) to more than groups are more sensitive to increased taxes on tobacco 1000 RMB a pack (20 cigarettes/pack and 10 packs/car- products and more often attempt to access cheap ton), thereby accommodating smokers from all income cigarettes through unconventional channels, such as levels. Although the wholesale tax on cigarettes in China purchasing cigarettes in duty-free shops, buying traf- has increased from 5 to 11%, it still lags far behind the ficked untaxed cigarettes, and hand rolling tobacco WHO (World Health Organization) recommended level leaves [8–10]. It is believed that the illicit tobacco of 67–80% [8] and makes cigarettes relatively cheap for market may account for as much as one in every 10 most smokers. cigarettes consumed globally [1]. Studies indicate that immigrants to industrialized countries often experience difficulty in finding suitable employment and usually obtain lower salaries than other * Correspondence: [email protected] – 1Kiang Wu Nursing College of Macau, Est. Repouso No.35, R/C, Macau, China citizens [12 14]. This difficulty is usually more apparent Full 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 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the 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 Page 2 of 8 among new immigrants than long-term immigrants, but Canadian; 2) currently smoked or quit smoking in the nonetheless immigrants often belong to social and past five years; and 3) lived in Canada for at least half a economically disadvantaged groups [7, 15–17]. Inversely, year. As per the original project, participants were new immigrants from cultures with high smoking preva- fathers who were expecting a child or had a child under lence also smoke more than older immigrants and main- the age of five years. Twenty-two men, recruited through stream populations before they adapt their smoking the Chinese forums (n = 21) or through the Chinese patterns to the norms of the new environment [18]. organizations (n = 1), met the study criteria and provided Chinese male smokers may experience challenges to informed consent. All participants were first-generation their continued smoking after they immigrate to devel- immigrants; two migrated to Canada with their parents oped countries, given the economic difficulties they before 18 years of age, and the other 20 migrated after encounter, combined with the probability of higher age 18. They had lived in Canada for an average of 8.7 ± priced cigarettes in the host country. Studies on Chinese 6.4 years (range = 0.5 to 22 years), 19 of the men for less immigrants’ smoking behaviors are limited. Several than 15 years. Characteristics of the sample are shown studies, mainly from the United States, report that in Table 1. Chinese immigrant smokers reduce their smoking more All 22 participants were smoking at the time they than other subpopulations [19–22]. Despite reductions, migrated to Canada. At the time of interview, 12 par- a substantial proportion of Chinese immigrants continue ticipants had quit smoking (defined as having stopped to smoke [23]. Poorly understood are the influences of smoking for at least one week) and the other ten had different tobacco markets in the host countries on substantially reduced their smoking. Two of the ex- Chinese immigrants’ smoking. smokers quit their smoking around five years ago This article is drawn from a qualitative study focused while the other ten quit within the last three years. on the smoking behaviors of Chinese Canadian immi- Among the current smokers, three smoked 10–18 grant fathers who smoke [24, 25]. As part of the study, participant’s access to cigarettes was investigated and these data were analyzed for the current article. Canada Table 1 Demographics and smoking patterns of the Chinese has a history of introducing comprehensive tobacco immigrants who smoked control measures and has continued to increase taxation Category Number of participants on tobacco products. As a result, Canada has one of the Education lowest smoking rates in the world, with a general smok- Elementary school and below 0 ing prevalence of 14.6% (16.0% among men and 13.3% among women) [26]. Junior/middle school 1 From 2006 to 2015, 290,912 new permanent residents High school 0 from China landed in Canada, and the Chinese comprise Non-university (collage, vocational, 3 the second largest foreign-born group in Canada [27]. It is technical, trade etc.) important to explore how cigarettes are accessed to Bachelor’s degree 13 inform tobacco control policy and the development of in- Master’s degree or over 5 terventions to reduce smoking among Chinese immigrants. Occupation Clerical/Administrative 5 Methods Construction/Manual Labor 7 Participant recruitment A qualitative descriptive approach as described by Technical/Skilled/Professional/Trade 7 Sandowski [28, 29] was used focusing on gaining a full Unemployed (Disabled, Student) 3 understanding of behaviors and practices from partici- Marital status pant perspectives. Bilingual recruitment advertisements Married 21 were distributed to Chinese organizations in the lower Divorced 1 mainland of British Columbia, Canada and posted on Amount Smoked Chinese online forums. The forums were publically accessible and hosted on websites in Canada with ≤ 10/day 7 Chinese language to serve Chinese Canadian immi- 10-20/day 3 grants. Potential participants were invited to contact the > 20/day 0 research team by telephone or email and then screened Quit Smoking 12 for eligibility. Age (years old) 38 ± 5.0 (28 to 46) Criteria for eligibility included the following: 1) self- Years in Canada 8.7 ± 6.4 (0.5 to 22) identified as a male Chinese immigrant or Chinese Mao et al. Tobacco Induced Diseases (2017) 15:18 Page 3 of 8 cigarettes per day (CPD) and the other seven smoked based on close readings of the first three interviews. fewer than 10 CPD. These emergent categories were organized and grouped into meaningful clusters and definitions developed to Data collection form a coding framework that was used to systematically Semi-structured interviews were conducted via tele- code the interview data. The qualitative data manage- phone with all the participants except one, with whom a ment program NVivo8 was used to code and retrieve face-to-face interview was conducted.