Behavioral Assessment Learning Issue 1

Anne Spini Public Health 540: Behavioral Assessment Professor: Renee Turchi, MD, MPH October 1, 2008 Case #1: Immigrant Health Traditional Asian Medicine and Smoking Cessation Introduction Traditional Asian medicine is an ancient practice that many people today use as a vital component of their healthcare (Bodeker 2002). In fact, the popularity of traditional Asian medicine is ever-increasing, and Coca-Cola just invested $80 million in a traditional Chinese medical research center with the intention of promoting holistic healthcare across the globe (Starling, 2008). Many non-Asians are strong supporters of traditional Asian medicine, but these traditional medical practices are especially important in the culture and beliefs of Asian people who have recently immigrated to the US (Uba 1992). Healthcare practitioners and public health policy makers in this country should utilize Eastern medicine, along with Western medicine, when treating Asian immigrants. This paper examines traditional Asian medicine and the role that it should play in smoking cessation among Asian immigrants at Philadelphia Health Care Center #N . Asian Americans make up less than 5% of the total U.S. population, and many people believe certain myths about Americans of Asian descent (Xueqin 1999). People do not understand the diversity of different Asian cultures and beliefs, people think that Asian Americans are a “model minority” (Xueqin 1999) that does not need public health interventions, and people think that Asian Americans represent such a small percentage of the U.S. population that their presence is almost insignificant (xueqin 1999). However, Asian Americans make up a large percentage of the populations of big cities throughout the U.S: 46% in Honolulu, HI; 18.4% in San Francisco, CA; 10.4% in Los Angeles, CA. Also, the population of Olney, a neighborhood in Philadelphia, PA, is

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Anne Spini Public Health 540: Behavioral Assessment Professor: Renee Turchi, MD, MPH October 1, 2008 Case #1: Immigrant Health 17.92% Asian (US Census Bureau, 2001). Overall, Asian Americans smoke at slightly lower rates than do other Americans (11% vs. 20%, respectively), but certain Asian American populations smoke at very high rates (CDC 2006). Generally, high rates of Southeast Asians (Vietnamese, Cambodian, and Laotian Americans) and Chinese men smoke. These groups smoke at a rate of about 30% (CDC 2006). While it is socially acceptable to smoke in Asian countries, Asian immigrants that move to anti-smoking states like California generally quit smoking (Zhu, et al., 2007). Of the Chinese and Korean immigrants living in California who have ever smoked, 53.3% quit smoking, whereas 11.5% of smokers quit in China and 22.3% quit in Korea (Zhu, et al., 2007). Being in an environment that discourages smoking is an important component of smoking cessation among Asian immigrants, but public health efforts aimed at helping this diverse population quit smoking need to consider the following important factor: smoking cessation programs targeting Asian immigrants should incorporate elements of traditional Asian medicine to be more successful. Western healthcare practitioners who treat Asian immigrant patients would benefit from learning about and putting into practice several traditional Asian medical procedures and ideas. Taking this step to make healthcare and public health programs more holistic would make them much more effective. Overview of Traditional Asian Medicine Traditional Asian medicine has been used for thousands of years, and Traditional Chinese Medicine (TCM), based on Taoist and Buddhist philosophies, is one of the oldest forms of traditional Asian medicine. TCM is a holistic health approach that includes acupuncture, massage, meditation, herbs, diet, and exercise remedies (Zheng, et

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Anne Spini Public Health 540: Behavioral Assessment Professor: Renee Turchi, MD, MPH October 1, 2008 Case #1: Immigrant Health al., 1995). TCM views the body as an interconnected system that is linked to the forces of nature, rather than as flesh and matter, the way Western medicine views the body (Zheng, et al., 1995). In China, modern and traditional medicine are both commonly used, and TCM accounts for 40% of distributed health treatments (Zheng, et al., 1995). The various systems of the body, such as yin and yang, as well as nature and the cosmos, are integrated to create the perfect balance that correlates with optimal health (Richardson, et al., 1986). Yin and yang describe any opposing forces in Chinese culture, such as fall and spring, and this concept is used to describe the opposing forces of the human body. Yin and yang are constantly conflicting with each other and sickness occurs if either of them is out of balance (Richardson, et al., 1986). Yin and yang apply to qi, the fundamental energy of the body systems, which flows through meridians, or channels. Qi is the opposite of blood, the other substance that travels through the body channels. Key to TCM is its unique map of the body, which describes blood, qi, and the organs in terms of function and their unification with other body systems (Richardson, et al., 1986). This unique map of the body is used by acupuncturists, who insert needles into certain points along which blood and qi flow in order to relieve pain or alleviate an illness (Richardson, et al., 1986). In the TCM model of the body, qi should be free flowing and relatively constant throughout the body, and the purpose of acupuncture is to fix blockages, deficiencies, or excesses of qi. Acupuncture is probably the most important component of TCM. It is used extensively throughout China and increasingly in the US, and it has even been used during surgeries as the sole form of anesthesia. Acupuncture,

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Anne Spini Public Health 540: Behavioral Assessment Professor: Renee Turchi, MD, MPH October 1, 2008 Case #1: Immigrant Health as well as other forms of TCM, is very difficult to fully learn, and TCM doctors must remain in training for many years (Richardson, et al., 1986). Another important component of TCM is the use of herbal medicines. Herbal therapy is a highly individualized treatment where the practitioner must analyze the patient’s balance of yin and yang and concoct a suitable formula that will only work if all the components are present in their exact quantities (Shaw, et al., 1997). Single ingredients do not function in herbal therapy, but the mixture of all ingredients is essential. Food and exercise treatments are also used to restore the balance of yin and yang (Shaw, et al., 1997). Foods that increase yin are generally warmer and richer in calories, so they can be used to alleviate a cold or hasten the circulation of blood and qi. Yang foods, used to improve a fever or detoxify the body, are cooler, lower in calories, milder, and generally contain more water (Shaw, et al., 1997). Massage, meditation, and exercise therapies are also used to change the yin/yang ratio by increasing or reducing blood flow, hydrating the body, and having a calming effect on the body (Shaw, et al., 1997). Traditional Southeast Asian medicine and traditional Korean medicine are similar in many ways to TCM in that they use acupuncture and herbal remedies. However, in addition to TCM practices, many Vietnamese, Cambodian, and Laotian doctors use a procedure called coining to treat a variety of conditions. In this procedure, hot coins are rubbed on the skin of the back, neck, or chest until red welts appear. These welts are thought to create a way for “bad wind” (Sullivan 2005) to exit the body. Coining is used to treat headaches, coughs, fevers, and to ward off evil spirits. There have been studies reporting that coining causes burns, bruises, and brain hemorrhage (Sullivan 2005).

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Anne Spini Professor: Renee Turchi, MD, MPH Case #1: Immigrant Health Efficacy of Traditional Asian Medicine

Public Health 540: Behavioral Assessment October 1, 2008

There has been much debate over the effectiveness of traditional Asian medicine, and findings remain inconclusive. Much research has been conducted on the usefulness of acupuncture in alleviating the symptoms of several diseases, and some studies find it to be helpful (Lee, at al., 2004) while others do not (Shaw, et al., 1997). Acupuncture has been found to be effective in helping to treat some illnesses. Conditions that have been shown to improve following acupuncture include nausea (Lee, et al., 2004), lower back pain, shoulder pain, and headache (Ernst, et al., 2007). Closely associated with the role of acupuncture in nicotine addiction, there is evidence suggesting that acupuncture is helpful in treating drug addiction through a biological mechanism (Yang, et al., 2008). Acupuncture has been found to decrease reinforcing effects of abused drugs by changing dopamine release, which affects several other brain neurotransmitter systems (Yang, et al., 2008). This research is important because it is one of the only conclusive studies on acupuncture and drug addiction that provides biological data. Other research (White, et al., 2005) on the effectiveness of acupuncture in smoking cessation has either been inconclusive or has concluded that acupuncture does not help people stop smoking. Additional research needs to be conducted in this field (White, et al., 2005). One traditional Chinese doctor in the US (Xueqin 1999) has found acupuncture to be extremely effective in helping patients to stop smoking. He finds acupuncture to decrease cravings for a cigarette by decreasing anxiety and increasing general well-being. When asked to describe his methods, this particular doctor stated the following:

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Anne Spini Public Health 540: Behavioral Assessment Professor: Renee Turchi, MD, MPH October 1, 2008 Case #1: Immigrant Health “When patients are ready to free themselves from the unwanted smoking habits, I provide them with acupuncture treatments. The treatment varies according to individual needs. Normally, very small needles are inserted into certain reflex points. They may feel a slight pinch, like a mosquito bite. The needles remain in place for a few minutes when they relax. Most patients quit smoking after one treatment. They may need one or two booster treatments if they are severely addicted. Acupuncture caused no unwanted side effects. After treatment, patients often feel relaxed, uplifted, and self-confident. They no longer feel a physical need for a cigarette” (Xueqin, 1999, p. 425). In a study (Liu, et al., 2008) on the effectiveness of mind-body-spirit group therapy and meditation for individuals with breast cancer, it was found that patients who participated in this holistic therapy experienced lower levels of anxiety than did people who were treated with only Western medicine. The mind-body-spirit group therapy, which incorporated TCM and Western medicine in sessions over a two-month period, was found to decrease apprehension and anxiety in breast cancer patients, allowing the patients to experience better healing (Liu, et al., 2008). Therapy that increases general well-being is also indicated in smoking cessation programs because it would make participants more likely to maintain their new lifestyle. There is also much debate over the effectiveness of herbal remedies and dietary supplements (Shaw, et al., 1997). There exist several studies suggesting that certain herbal treatments used in Traditional Asian Medicine can even be detrimental to the body. In a study (Shaw, et al., 1997) conducted in the UK of 1297 individuals with new health problems who had been receiving herbal treatments, 785 people were found to

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Anne Spini Public Health 540: Behavioral Assessment Professor: Renee Turchi, MD, MPH October 1, 2008 Case #1: Immigrant Health have liver problems, allergic reactions, and heavy metal poisoning caused by the herbal remedies (Shaw, et al., 1997). Chinese herbal remedies are currently very popular in Britain, and in another case, a skin cream, which consumers thought to be made of all natural ingredients, was found to contain steroids (Graham-Brown, et al., 1994). This skin cream is very misleading to consumers and also illegal, since medicines that contain high levels of steroids cannot be sold without a prescription in Britain. Herbal treatments can possibly be helpful for certain conditions, but consumers need to be aware of exactly what they are taking. There has not been much research done on the use of herbal remedies for smoking cessation, but these treatments are probably not helpful for this application (Graham-Brown, et al., 1994). Public Health Programs and Research Involving Traditional Asian Medicine A study (Xueqin 1999) was conducted on the healthcare access and usage of Chinese immigrants in the US. Western medicine has a long way to go in recognizing and accepting traditional healthcare beliefs and practices of other cultures. Because many Western practitioners are completely ignorant about TCM (Xueqin 1999), some Chinese immigrants are distrusting of these doctors. While many Chinese immigrants do accept the validity of Western medicine, most of them do not solely use this type of healthcare. The study (Xueqin 1999) consisted of 75 Chinese immigrants living in Houston and Los Angeles. Participants were all at least 25 years of age, and they were from varying socioeconomic backgrounds. The following healthcare patterns were reported among these individuals: 94.6% used alternative/home remedies; 45.3% used both Western and traditional healthcare; 32% traveled to China or Taiwan for healthcare;

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Anne Spini Public Health 540: Behavioral Assessment Professor: Renee Turchi, MD, MPH October 1, 2008 Case #1: Immigrant Health 25.3% used traditional Chinese clinics in the US; 21.3% primarily used Western clinics (Xueqin 1999). These results show that Western healthcare needs to become more holistic and it needs to incorporate more alternative medicine in order for Chinese immigrants to feel comfortable using it (Xueqin 1999). Another public health study (Uba 1992) found that Southeast Asian refugees in the US suffer significant health problems due to physical trauma and to a lack of sufficient healthcare in Asia, but that these immigrants under use healthcare services in the US, even when they have access to these services (Uba 1992). While Southeast Asian immigrants deal with significant economic barriers to healthcare, the bigger problem contributing to their lack of healthcare might be cultural. Common cultural beliefs of Southeast Asian populations include the idea that suffering is unavoidable and that the human lifespan is predetermined (Uba 1992). Southeast Asian immigrants probably experience more apprehension and distrust of Western medicine than do other Asian immigrant populations, since they are the least acculturated of the Asian immigrant populations (Uba 1992). Southeast Asians also do not understand Western healthcare diagnosis and treatment (Uba 1992). The US healthcare system is still behind that of Europe in accepting traditional Asian medicine, but it has come a long way in the last 10-20 years (Xueqin 1999). In 1992 the National Institute of Health created the Office of Alternative Medicine to conduct research on traditional healing (Xueqin 1999). This type of medicine had become much more popular among the general public, and the Office of Alternative Medicine was given a budget of $2 million (Xueqin 1999). Another study (Bodeker, et al., 2002) confirmed the increasing popularity of traditional medicine. In 2002, about

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Anne Spini Public Health 540: Behavioral Assessment Professor: Renee Turchi, MD, MPH October 1, 2008 Case #1: Immigrant Health 50% of people in developed countries used some form of traditional medicine, and public health research is continuing to be conducted on the safety and effectiveness of this type of medicine (Bodeker, et al., 2002). The fields of public health and medicine are making efforts to understand and put into use traditional medical practices (Wetzel, et al., 1998). Integral to the development of more culturally sensitive physicians is the inclusion of courses on traditional medicine in medical schools. In a study of the US medical schools (Wetzel, et al., 1998), 60% were found to offer elective courses on traditional medicine. However, there are huge differences in the content, format, and amount of material covered in these courses. To better treat immigrant populations in the US, medical school curriculums need to be improved (Wetzel, et al., 1998). The Importance of Traditional Asian Medicine to Case 1 – Immigrant Health Traditional Asian medicine is a topic of great importance in the design of smoking cessation programs for Southeast Asian populations in Philadelphia Health Care Center #N. After researching the tremendous significance of traditional medicine in Southeast Asian culture (Uba 1992) and the growing credibility of traditional medicine in the medical and public health communities (Lee 2004), it is my recommendation that traditional Asian medicine be an integral component of smoking cessation programs. Leaders of smoking cessation support groups should be trained in the theory behind traditional Asian medicine, and they should have substantial knowledge about acupuncture and meditation. Physicians who are practitioners of these techniques should be consulted, and their services should be made available to patients at Philadelphia Health Care Center #N. The leaders of the support groups and the physicians should

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Anne Spini Public Health 540: Behavioral Assessment Professor: Renee Turchi, MD, MPH October 1, 2008 Case #1: Immigrant Health collaborate, so that both providers are aware of how each patient is doing in all aspects of the smoking cessation program. By providing this holistic approach to smoking cessation, it is expected that participants of the program will have a better chance of quitting smoking and maintaining their abstinence from tobacco. Conclusion Many Asian immigrants living in the US have very strong cultural ties to their country of origin, so traditional Asian medicine is very important to these people (Xueqin 1999). Asian Americans are not very well understood by Western healthcare providers and the US population in general (Xueqin 1999). Asian immigrants are seen as a “model minority” (Xueqin 1999) that does not need to be the focus of public health interventions, but in reality, many Asian Americans live in poverty and lack access to healthcare. Oftentimes, Asian immigrants who do have access to healthcare do not make use of this service due to cultural beliefs and distrust of Western medicine (Xueqin 1999). It is thought that Asian Americans do not generally smoke (Xueqin 1999), but Chinese men and Southeast Asians living in the US smoke at high rates (CDC 2006). Healthcare providers and public health policy makers need to focus more on traditional Asian medicine when providing smoking cessation services to Asian American patients. By doing so, these patients will be much more likely to seek out the services of healthcare providers in the US, and smoking related illnesses will be prevented to a large degree. Traditional Asian medical practices that help people stop smoking, such as acupuncture, should be offered by more doctors in the US. These physicians also need to know how to communicate better with their Asian patients so they can successfully advise them against practices that might be detrimental to their health, such as dangerous herbal medicines

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Anne Spini Public Health 540: Behavioral Assessment Professor: Renee Turchi, MD, MPH October 1, 2008 Case #1: Immigrant Health and coining. More research needs to be conducted on the efficacy and the safety of traditional Asian medicine. By applying traditional Asian medical techniques to the smoking cessation program at Philadelphia Health Care Center #N, the program will be more effective. Questions for Discussion 1. How should healthcare providers respond when Asian immigrant patients insist on using cultural treatments that have been shown to cause adverse side effects and suffering, such as coining (some people who use coining on their children have been accused of child abuse)? 2. Should courses in traditional cultural medicine be optional or required in medical schools? 3. What should public health policy makers do to provide better healthcare to underserved Asian populations?

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Anne Spini Professor: Renee Turchi, MD, MPH Case #1: Immigrant Health

Public Health 540: Behavioral Assessment October 1, 2008 References

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