Developing a Culturally Relevant Community Centered eHealth Smoking Cessation Intervention (CCeSCI): a Qualitative Study on the Beliefs and Attitudes of Chinese Smokers and Community Workers

Abstract

Background: The prevalence of smoking among Chinese men has been one of the highest globally despite decades of smoking cessation efforts. Previous studies suggest that smoking cessation interventions could be more effective in achieving abstinence when they are culturally adapted. Based on the “smoking rationalization belief” framework and recent development on electronic health (eHealth) technology, we developed the Community Centered eHealth Smoking Cessation Intervention (CCeSCI).Research question: What are the common beliefs of East and Southeast Asian male smokers that make quitting so difficult, and how can we inform and refine the CCeSCI trial design and implementation in order to address those cognitive misconceptions and to achieve a better quitting outcome? Method: We conducted a comprehensive literature review on the common beliefs of East and Southeast Asian smokers and a qualitative study on beliefs and attitudes of Chinese smokers and community workers to inform the CCeSCI study design and implementation. A total of eighteen in-depth interviews were conducted, including five with community workers and thirteen with adult male smokers. The smoking rationalization belief framework (including six domains) was used to guide the thematic analyses of the qualitative data. Findings: Both the literature review and the qualitative study revealed that the six domains in the rationalization beliefs framework -- smoking functional beliefs, risk generalization beliefs, social acceptability beliefs, safe smoking beliefs, self-exempting beliefs, and "quitting is harmful" beliefs -- were the major themes of male smokers. In addition, fatalism, family matters, no need for help, indifference and pessimism, and "I can quit when I decide to" were the most popular attitudes among smokers. For community workers, the major themes were "environmental factors are the most important," "leadership support is crucial," "mixed attitudes regarding cessation clinics," and "individual willingness matters." We also identified some common barriers to smoking cessation efforts. We found high heterogeneity among smokers in their beliefs and attitudes, but less so for community workers. Conclusions: Current smoking cessation efforts have largely neglected the rich diversity of rationalization beliefs among smokers and the misalignment of perceptions between community workers and smokers. Future interventions should focus more on addressing the specific psychological dependence of smokers and their rationalization beliefs by placing them at the center of their decision-making. Integrated with supply-side intervention in the communities and eHealth technologies, CCeSCI has a promising future in improving smoking abstinence with better acceptability, feasibility, and generalizability among adult male smokers in East and Southeast Asian countries.