Smoking Cessation Interventions for Chinese American Smokers: A Systematic Review and Meta-Analysis

Background: Smoking cessation interventions are important for decreasing lung cancer mortality rate among Chinese Americans. This study aims to investigate and summarize the intervention methods focusing on smoking cessation among Chinese Americans and to compare the effects of intervention methods on the smoking cessation rates. Methods: A systematic review and meta-analysis design was used in this study. Keyword searching was conducted in August 2021 on PubMed, Google Scholar, PsycINFO, and CINAHL. The methodological quality of each study was assessed using the PEDro scale or The Methodological item for non-randomized studies (MINORS). The Review Manager Version 5.4 software was used to conduct the meta-analysis. Random effect model and subgroup analysis were applied in the analysis. Results: Twenty and 11 studies were included in the systematic review and meta-analysis, respectively. Of the 20 studies, 8 were randomized control studies, 9 were pre-post single group intervention studies, 1 was retrospective analysis for an intervention study, 1 was a baseline data analysis from a cluster randomized trial, 1 was a feasibility intervention study. Results showed that compared to the control group, the group that received interventions on smoking cessation had a significantly increased smoking cessation rate (OR, 3.76; 95% CI, 1.72-8.21; P=0.0009). Subgroup analysis showed individual-based (OR, 5.88) NRT outreach interventions (OR, 3.80) conducted in person (OR, 2.53) with smokers (OR, 6.64) seemed to be more effective to increase smoking cessation rates among Chinese Americans compared with group-based, telephone counseling, indirect remote interventions conducted among Chinese American smokers and their non-smoke family members. Conclusions: Individual-based NRT outreach interventions conducted in person with smokers is an effective way to increase smoking cessation rates among Chinese Americans. More culturally sensitive and effective interventions are needed to help Chinese American smokers to quit smoking.

Introduction rate among Chinese Americans was relative high, ranging from 17.4% (Yu, Chen, Kim, and Abdulrahim, 2002) to 18%  and, much higher in men (29% to 34%) than in women (2% to 4%) Yu et al., 2002), whereas the smoking rate was 15.1% in U.S. adults, 17.5% among U.S. men and 13.5% among U.S. women aged 18 years and older in the United States (Jamal et al., 2016). The primary approach to prevent lung cancer is smoking cessation, which has been proved effectively decreasing the incidence rates of lung cancer among males and females (American Cancer Society, 2019). Population-based studies in Asian have revealed a sharp decrease of lung cancer risk for over 50% in the first 5 to 6 years of smoking cessation (Tse et al., 2011;Wong et al., 2010). The US Preventive Services Task Force recommends long-term smokers to quit smoking for 15 years before their risk of getting lung cancer comparable to non-smokers (U.S. Preventive Services Task Force, 2021).
Smoking cessation interventions are important for decreasing lung cancer mortality rate among Chinese

Fang Lei*, Ying Zheng
Americans. Although no review study has been reported on the smoking cessation interventions in Chinese Americans, previous studies indicated a paucity of smoking cessation interventions for Asian Americans, which also included Chinese Americans (Doolan and Froelicher, 2006). While a review study conducted in 2003 showed 4 studies had reported smoking cessation interventions in Asian/Pacific Islanders from 1985 to 2001 (Lawrence et al., 2003), a review conducted in 2007 showed that only two clusters of controlled studies and one uncontrolled smoking cessation intervention study focusing on Asian Americans have been published from 1995 to 2005 (Chen et al., 2007). In addition, another review study published in 2011 showed only 3 studies had been conducted on smoking cessation treatment among Asian Americans from 1985 to 2009 (Cox et al., 2011). These studies suggest the need for continued efforts to develop and evaluate the effectiveness of smoking cessation interventions for Asian American populations including Chinese Americans (Lawrence et al., 2003). Further research relevant to the smoking cessation needs of minority populations can enable nurses and other healthcare providers to administer culturally adequate and efficacious smoking cessation interventions to these groups (Doolan and Froelicher, 2006).
The research questions aimed to be answered in this study were two-fold: (1) What intervention methods have been used for increasing smoking cessation rates among Chinese Americans in the past years? and (2) Which intervention methods are effective and how effective are they? The purpose of this systematic review and meta-analysis is to investigate and summarize the intervention methods focusing on smoking cessation among Chinese Americans and to compare the effects of intervention methods on the smoking cessation rates. This study will provide a comprehensive picture of the intervention programs which have been done on smoking cessation for Chinese Americans over the past years. It will also suggest an optimal way to increase smoking cessation rates among Chinese Americans.

Search Strategies and Selection Criteria
Keyword searching was conducted in August 2021 on PubMed, Google Scholar, PsycINFO, and CINAHL. Search strategies included [(smoking cessation) OR (quit smoking) OR (tobacco cessation) OR (tobacco quit)] AND (Chinese American*). Inclusion criteria for the studies were: 1) peer-reviewed studies, 2) intervention studies, 3) targeted at Chinese Americans or Asian Americans including data about Chinese American population; and 4) studies with relevant data about smoking cessation outcomes. Exclusion criteria for the studies were: 1) review studies; or 2) not meeting the inclusion criteria.
Guided by the PRISMA literature search process, we checked the titles of the articles first, then the abstracts of the articles were evaluated, and last the text and references of the articles were read further for inclusion and exclusion consideration. The authors of this study did the literature search separately. The initial searching results were compared and discussed among the authors to reach consent. Information on the studies' designs, settings, samples, interventions, outcomes, and results were entered to the table of evidence by the first author and verified by the second author.

Data Synthesis and Study Quality
We organized the systematic review results into logical categories according to group consensus. The methodological quality of randomized control trial studies was assessed using the PEDro scale (www. pedro.fhs.usyd.edu.au). The methodological quality of the pre and post intervention studies was assessed using The Methodological item for non-randomized studies (MINORS). The agreement between the two assessors was evaluated with the intraclass correlation coefficient (ICC).
The PEDro scale comprises a list of 11 criteria. Each criterion is valued by either 0 ("No) or 1 ("Yes"), with only 10 of them used (item 2 to 11) to calculate the total score, yielding a maximum score of 10 points for each assessed study. The item 1 of the PEDro scale is only used for evaluating the studies' external validity, but not used for evaluating the intervention studies' quality, according to the recommendation from the designer of the PEDro scale (www.pedro.fhs.usyd.edu.au). Studies with a score lower than 4 are considered 'poor' quality, 4 to 5 are considered 'fair', 6 to 8 are considered 'good' and 9 to 10 are considered 'excellent' (Cashin and McAuley, 2020).
The MINORS tool contains a list of 12 criteria. The first 8 items are applicable for both non-comparative and comparative studies. The last 4 items are appropriate for studies with two or more groups. Every item is scored from 0 to 2, and the total scores over 16 or 24 give an overall quality score.

Data Analysis
The Review Manager Version 5.4 software was used to conduct the meta-analysis. Random effect model and subgroup analysis were applied in the analysis. The Hedge's g statistic was used, and sample size was weighted. Raw data (e.g., mean with standard deviation) in the studies were converted to percentage. The Tau 2 statistic was used to evaluate the included studies' heterogeneity, and I 2 statistic was utilized to reveal the variance among the studies. With a I 2 value between 0% and 25%, the studies were considered zero heterogeneity; 25% to 50% was low heterogeneity, 50% to 75% was moderate heterogeneity, and 75%-100% was high heterogeneity (Higgins et al., 2003). We assessed risk of bias within studies according to the PRISMA recommendation using a tool based on Agency for Healthcare Research and Quality guidance (Viswanathan et al., 2012). The first author did the data analysis and the second author reviewed and verified the results.

Study characteristics
The search yielded 20 eligible articles to be included in the review. A detailed searching process could be found in Figure 1. Of the 20 articles reviewed in this study, 8 curriculum Shelley et al., 2008), flip chart , video/audiotapes  , behavior skill training , patient navigation , wechat message , acupuncture , text-messaging , pharmacotherapy , and holding quit and win contest  were conducted in the studies. More information about the intervention characteristics of the included studies can be found in Table 2.

Study Quality
Of the 20 eligible papers, 11 studies were included in the meta-analysis. Among the 4 studies evaluated by PEDro scale, two were good quality trials Zhu et al., 2012), and two were fair quality trials Wu et al., 2009). Among the 7 studies evaluated by MINORS, the scores for the quality evaluation ranged from 12 Lau et al., 2020;Shelley et al., 2008;Shelley et al., 2010) to 20 (Chang et al., 2003) with one study  having a score of 14. The score of each individual study's quality constituted the average value of the scores given by the two assessors. The ICC was 0.88 (95% CI: 0.47-0.99). Details about the study quality evaluation was shown in Tables 3 and 4.

Publication Bias
For the outcome of interest, funnel plot ( Figure 2) was generated for evaluation of publication bias. The distribution of data points provided limited evidence for small study publication bias.

Meta-Analysis of the Smoking Cessation Interventions Total effect
Of the 20 studies which tested the effects of interventions on participants' smoking cessation rates, nine studies Cummins et al., 2015;Daniel et al., 2021;Ma et al., 2005;Tat et al., 2016;Tsoh et al., 2015;Wong et al., 2008;Young et al., 2020;Zhao et al., 2019) were not included in the meta-analysis due to lacking data on the smoking cessation rate among Chinese American participants. Results showed that compared to the control group, the group that received interventions on smoking cessation had a significantly increased smoking cessation rate. The pooled summary effect of the interventions included was 3.76 times higher in comparison to the control (OR, 3.76; 95% CI, 1.72-8.21; P=0.0009). However, a high heterogeneity was noticed across the study results (Tau 2 =1.16, ChI 2 =77.85, df =10, P<0.00001, I 2 = 87%) ( Figure 3).

Subgroup Analysis Individual-vs. group-based interventions
Of the 11 included studies which tested effects of the interventions on Chinese American participants' smoking cessation rates Fang et al.,2006;Ma et al., 2004;Shelley et al., 2008;Tong et al., 2018;Wu et al., 2009;Zhu et al., 2012), nine studies were individual-based intervention were randomized control studies Fang et al.,2006;Tong et al., 2018;Wong et al., 2008;Wu et al., 2009;Young et al., 2020;Zhao et al., 2019;Zhu et al., 2012), 9 were pre-post single group intervention studies Chen et al., 2021;Lau et al., 2020;Ma et al., 2004;Ma et al., 2005;Shelley et al., 2008;Shelley et al., 2010;, 1 was retrospective analysis for an intervention study , 1 was a baseline data analysis from a cluster randomized trial , 1 was a feasibility intervention study . Most of the studies were conducted in New York City. Sample size of the studies ranged from 26  to 14073 . The publication years of the studies ranged from 2004 to 2021. More information about the study characteristics of the included studies can be found in Table 1.
In addition, sixteen of the studies are individual-based studies Chang et al., 2013;    Pre-post-test US A minimum of 9 proactive phone counseling sessions within a 6-month period for each participant recruited at his worksite All activities were conducted in Chinese languages.
Randomized control trial US A multistate cessation quit line from 1/2010-7/2012 A comprehensive session to prepare for quitting and follow-up calls scheduled according to the risk of relapse (i.e., front-loaded). Experienced quit line counselors who were bilingual and bicultural provided the counseling. The self-help materials were also used from the efficacy trial Chinese speakers chose whether to receive booklets with traditional or simplified characters.
No separate data for Chinese American smokers  Baseline data analysis from a cluster randomized trial Northern California Family-based healthy lifestyle intervention. Two small group education sessions about "quit Smoking for a Healthy Family" and two individual telephone calls over 2 months.
The comparison LHWs will receive training about "Healthy Living" focusing on nutrition and physical activity education. Participants will also receive the Smoking Cessation Resource Handout.

Chinese and Vietnamese American male daily smokers
No specific data about smoking cessation rates Fang et al. (2006)

NA
Week 12 smoking cessation rates: 13.9%, Sixteen participants successfully quit smoking. Lau et al. (2020) Pre-post single-arm quasi-experimental study New York City A health coach-led smoking cessation program from November 2015 to January 2017 Follow-up was provided face-to-face or over-the-phone to provide support and address barriers.
Free nicotine replacement treatment was provided for eligible participants. NA 184 Chinese American participants NA 3 month smoking cessation rates: An intent-to-treat analysis found that 19% quit. A culturally modified pro-gram (ACT) Chinese American male (n = 17) youth smokers, aged 14-19 years n=13 at 3-month follow-up Chinese Ameri-can male (n = 9) youth smokers, aged 14-19 years n=9 at 3-month follow-up Post program smoking cessation rates: SC vs. ACT: 22.2% (n=17) vs. 0% (n=9) A 23.1% quit rate for the SC program (n=13) and an 18.2% quit rate for the ACT program (n=9) at 3-month follow-up was achieved. Mainly staffed by four well-trained, volunteer undergraduates, explained the risks of firstand second-hand tobacco exposure and how to access the Helpline's services. A brochure, provided in English, Chinese, Korean, and Vietnamese (the Helpline's available Asian languages), was used to guide the bicultural, bilingual students' tobacco-related discussions with shoppers. The students' repeated presence at the nine partner-ing Asian grocery stores served as reminders of the Helpline's availability.

NA
No specific data about smoking cessa-tion rates Tong et al. (2018) Randomized con-trolled trial San Francisco, California Moderate-intensity smoke-free-living educational intervention 2 group sessions, a laboratory report of their baseline smoke exposure, as measured by 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), and 3 follow-up calls over 6 months A brief-intensity smoke-free-living educational intervention 1 group session on tobacco-cessation resources Graphic, quit line group A graphic, native language text-messaging intervention Participants were randomly assigned to one of four conditions based on a between-subjects 2 (graphic plus text or text-only messages) * 2 (quit line information or quitting tips) design. The text-messaging intervention included 30 text messages in total and lasted one month. Participants completed an expired air carbon monoxide (CO) assessment and self-reported measures at both baseline and follow-up.  Chang et al., 2013;Lau et al., 2020;Tong et al., 2018;Wu et al., 2009;Zhu et al., 2012) and two studies were group-based intervention studies Shelley et al., 2008). Results showed that compared to the control group, the individualbased interventions significantly increased participants' smoking cessation rates. The pooled summary effect of the included individual-based interventions was 5.88 times higher compared to the control (OR, 5.88; 95% CI, 2.20-15.74; P=0.0004); the same effect was noticed on the group-based interventions; however, the increase was not significant (OR, 1.02; 95% CI, 0.75-1.39; P=0.90). With subgroup analysis, the heterogeneity across the studies decreased both among individual-based studies (Tau 2 =1.57, ChI 2 =58.87, df = 8, p<0.00001, I 2 = 86%) and group-based studies (Tau 2 =0.00, ChI 2 =0.00, df = 1, p=0.98, I 2 = 0%) (Figure 4). Proactive phone-counseling intervention: a minimum of 9 proactive phone counseling sessions within a 6-month period for each participant recruited at his worksite. All activities were conducted in Chinese languages. comparing baseline smoking with smoking 6 months after the intervention ended.
Smoking-cessation products (Chinese quit-smoking tea; ginger candy; NRT patch) were free and delivered in person to participants for whom they had been recommended.

Individual
Indirect remote Telephone counseling + NRT outreach Smokers-based  The intervention consisted of one individual office counseling session, and two group class sessions with options offered for acupuncture treatments and NRT. The self-selected treatment groups were categorized as (a) only acupuncture, (b) only NRT, and (c) acupuncture + NRT. The individual counseling, including in the group class sessions, was conducted by the bilingual, bicultural health education staff. Acupuncture was provided by a Chinese physician with medical acupuncturist training and a licensed acupuncturist. Up to six needles were used in each area, most commonly elbows, knees, and earlobes. For participants who declined acupuncture therapy or were waiting for needle placement, counselors helped them set up a quit plan and strategies for reduction and cessation. All needles were in place within the first 30 minutes; those who received acupuncture first had therapy the longest, but all had therapy for at least 15 minutes. Prescriptions for nicotine patches were offered, and patients were responsible for picking up the medications from their pharmacies. Medication costs were covered by Medi-Cal or the county insurance, which also has a program that provides coverage to uninsured residents. Acupuncture was provided free of charge.

In person
Office counseling + acupuncture + NRT outreach Smokers-based  Participants received behavioral telephone counseling from counselors fluent in Chinese, Korean, or Vietnamese. Participants also received 2 weeks' worth of nicotine patches mailed directly to their homes.

Individual
Indirect remote Telephone +

NRT outreach
Smokers-based Cummins et al., 2015 Toll-free Asian-language quit line service. The multistate service also used the self-help materials from the efficacy trial, which were designed to motivate smokers to make quit attempts and to teach the skills needed to avoid relapse. Chinese speakers chose whether to receive booklets with traditional or simplified characters.

Indirect remote Telephone counseling + self-help materials
Smokers-based  Randomization in one of two family-based educational interventions. Family-based healthy lifestyle intervention: two small group education sessions and two individual telephone calls over 2 months on topic of "Quit Smoking for a Healthy Family".

Group
In person Health education + telephone call follow-up Smokers and non-smoke family memberdyads based  A theory-based smoking cessation intervention vs. general health counseling +nicotine replacement therapy one in-person session lasting approximately 90-120 min and targeted cognitive-affective reactions to smoking and cessation. Cultural values and culturally appropriate quitting strategies, such as the importance of familial support, concerns relating to children's health, and having a healthy Asian diet, were employed to assist and encourage participants during their quit attempts. Follow-up assessments were conducted by telephone at one-week, onemonth, and three-month post-counseling and assessed health beliefs and smoking status. All study procedures and assessments were conducted in the participant's native language (Korean, Cantonese, or Mandarin).

Individual
In person Patient counseling + NRT outreach Smokers-based  A culturally and linguistically relevant, physician-led smoking cessation intervention. Pharmacological treatments and brief cessation counselling, education and support by the physician and the health educator.

In person
Office counseling+ NRT outreach Smokers-based Lau et al., 2020 A health coach-led smoking cessation program. Follow-up was provided face-to-face or over-the-phone to provide support and address barriers. Free nicotine replacement treatment was provided for eligible participants.

In person+ indirect remote
Office counseling/ Telephone + NRT outreach Smokers-based Ma et al., 2004 The American Lung Association's Not on Tobacco (N-O-T) curriculum was selected as the generic curriculum. The study was conducted over a period of 6 weeks during the summer of 2001 and used a pre-post quasi-experimental research design using two related samples. A buddy system was developed, and participants received more monetary rewards if they brought their respective buddies and additional incentives (t-shirts, gift certificates) if they continued to attend the sessions.   Ma et al., 2005 During the intervention, a counselor met with each participant individually for approximately two hours. At the beginning of the session, participants were asked to complete a baseline smoking behavior questionnaire. The intervention was in accordance with current nicotine addiction treatment guidelines. The program was designed to be time-, labor-, and cost-effective, without compromising its efficacy; it entailed smoking cessation advice along with nicotine replacement therapy (NRT). Participants who were interested in the use of NRT were screened for eligibility for nicotine patch use and were provided usage instructions and free patches. These programmatic features were designed especially for underserved and hard-to-reach minority populations.

Individual
In person

Patient navigation + NRT outreach
Smokers-based  Physician education and detailing which included 1) the distribution of "Tool Kits" to 99 physicians in 42 practices; 2) distribution of 305 six-week courses of free nicotine patches through ACS and AAFE; 3) implementation of three free Chinese-language smoking cessation programs that included free pharmacotherapy (one hospital-based and two located in community-based health centers); 4) a quit and win contest (50 participants) and; 5) 13 smoking cessation workshops conducted by ACS (122 attendees). The launch of city-wide tobacco control initiatives sponsored by the NYCDOH. These included a cigarette tax increase of $1.50 per pack, that when combined with the NY State excise tax raised cigarette taxes to $3.00 per pack, and the enactment of the Smoke Free Air Act. NYCDOH also launched a citywide media campaign in English and Spanish, however, they did not distribute a Chinese-language educational campaign during the intervention period.

Group
In person NRT outreach + patient education curriculum + pharmacotherapy + quit and win contest + health education Smokers and physicians-based  A 6-week course of the nicotine patch Kits contained a 2-week supply each of generic 21, 14, and 7 mg patches, instruction sheets and a self-help smoking cessation guide. All written materials were provided in Chinese and English.

Individual
In person NRT outreach smokers-based Tat et al., 2016 The new module, mainly staffed by four well-trained, volunteer undergraduates, explained the risks of firstand second-hand tobacco exposure and how to access the Helpline's services. A brochure, provided in English, Chinese, Korean, and Vietnamese (the Helpline's available Asian languages), was used to guide the bi-cultural, bi-lingual students' tobacco-related discussions with shoppers. The students' repeated presence at the nine partnering Asian grocery stores served as reminders of the Helpline's availability.

Individual
In person Health-education Smokers-based Tong et al., 2018 The moderate-intensity group pairs received two 90-minute educational sessions over 3 months, individual laboratory reports of baseline tobacco exposure, a bilingual booklet that summarized the educational materials and included self-reflection questions, and 3 individual follow-up calls (<15 minutes) over 6 months. The brief-intensity group pairs received 1 hour of education. The educational sessions primarily consisted of PowerPoint presentations and group discussions delivered by the CPHC health educator. All participants received a project magnet with scheduling information.

Individual
In person

Health education +telephone call
Smokers and household nonsmokersdyads based Tsoh et al., 2015 The 2-month SNFF intervention involved LHW outreach to both smokers and families through two small group education sessions with smoker-family dyads (90 minutes each) and two LHW-delivered individual telephone calls (10-15 minutes each) to reinforce progress and provide support. The size of each small group ranged from 2 to 4 dyads. Education sessions involved engaging participants sharing their personal stories, teaching with a flip chart, and setting individual goals using a "Health Family Action Plan." The flip chart was made of hard laminated cardboard and able to stand on its own base. Bulleted speaking points for the LHW in English, Chinese, and Vietnamese were on one side of each page while the other side had a headline, brief explanatory text, and culturally appropriate graphics.

Group
In person Health education + flip chart + telephone call Smokers and family member dyads-based Wong et al., 2008 Participants assigned to the minimal intervention group received (a) a strong message to quit smoking from their primary care physician and/or the research nurse, (b) a self-help manual with information on pharmaco-therapies, and (c) a list of smoking cessation programs available in the San Francisco Bay Area. Smokers in the intensive group also received 45-minutes of cognitive behavioral counseling as well as the smoking cessation video and the relaxation audiotapes to view or listen on their own. For those patients who reported less than 75% confidence on the self-efficacy scale to resist smoking during high-risk situations, behavioral skill training was provided.   Wu et al., 2009 Adapted MI counseling + self-help smoking cessation materials vs. health education sessions + general health self-help information Intervention consisted of four 60-min in-person sessions of Adapted MI counseling and a packet of self-help smoking cessation materials. The deleterious effects of tobacco use, secondhand smoke, as well as participants' experiences with smoking were discussed within various cultural contexts as, for example, hosting friends or in business transactions. Additionally, participants were counseled about the addictive nature of nicotine, encouraged to conduct a decisional balance exercise to examine the pros and cons of smoking, and encouraged to contemplate quitting behavior. Participants were provided NRT packs and counseled on their use.

In person
Patient counseling + self-help materials + NRT outreach Smokers-based  WeChat participants received weekly culturally sensitive smoking cessation WeChat messages for 6 weeks. Follow-up surveys were administered via WeChat at 1 and 3 months. This study reports user engagement, satisfaction, knowledge gain and quit attempts at 1and 3-month follow-up.

Indirect remote
Wechat message Smokers-based Zhao et al., 2019 The study consisted of a baseline survey and biochemical assessment, a one-month text-messaging intervention and a follow-up survey and another biochemical assessment. Participants received either graphic plus text or text-only health messages depicting the physical and social harms of smoking. They also received either information about an Asian-language Quitline or culturally tailored tips for quitting adapted from an existing smoking cessation text-messaging program, SmokeFreeTXT and its application in China.

Indirect remote
Text-messaging Smokers-based Zhu et al., 2012 Smokers in the counseling group received telephone counseling in addition to the self-help materials.

Discussion
This study examined the effects of smoking  Burton et al., 2010;Chang et al., 2003;Lau et al., 2020;Shelley et al., 2008;Shelley et al., 2010 Inclusion of consecutive patients Burton et al., 2010;Chang et al., 2003;Lau et al., 2020;Shelley et al., 2008;Shelley et al., 2010 Prospective collection of data Burton et al., 2010;Lau et al., 2020;Ma et al., 2004;Shelley et al., 2008;Shelley et al., 2010 Endpoints appropriate to the aim of the study Burton et al., 2010;Chang et al., 2003;Lau et al., 2020;Shelley et al., 2008;Shelley et al., 2010 Unbiased assessment of the study endpoint Burton et al., 2010;Chang et al., 2003;Lau et al., 2020;Shelley et al., 2008;Shelley et al., 2010 Follow-up period appropriate to the aim of the study Burton et al., 2010;Chang et al., 2003;Lau et al., 2020;Shelley et al., 2008;Shelley et al., 2010 Loss to follow up less than 5% Chang et al., 2003;Ma et al., 2004 Prospective calculation of the study size 0  Utilizing appropriate intervention methods to increase smoking cessation rates among Chinese American smokers is necessary. First, an individual-based smoking cessation intervention can help to bring personal-targeted culturally sensitive intervention content to individual Chinese American smoker. It can help them to overcome the barriers which they face during their smoking cessation process. Based on the individual targeted interventions, approaches such as individual motivational interview, personal counseling with smoking cessation experts, and one-on-one smoking cessation collaborator could be used to help Chinese American smokers to quit smoking. Second, NRT outreach can help to provide necessary tobacco substitutes to addicted Chinese American smokers, which can help them to suffer less from the withdraw effect of quit smoking. In recent years, using NRT outreach as the main method to help smokers to quit smoking and assisting with the telephone counseling to facilitate the usage of NRT products is the trend to be used in smoking cessation projects (Fu et al., 2016). Third, in person interventions could help to build a close rapport between smokers and interveners. In person interventions which happen face to face can help smokers get familiar with the interveners easier and faster. Also, interactions between smokers and interveners could be facilitated through various methods conducted in person, such as role play intervention games, counseling with paper-based materials' assistance, introduction of a smoking cessation buddy, etc. Last, smokers-based interventions seemed more effective for smokers to quit smoking than interventions focusing on both smokers and their non-smoke family members. This finding answered the concern which raised by Hubbard et al., (2016) in their systematic review study, which stated that most studies did not assess the influence of family involvement in the interventions on smoking behavior, because there was no direct study comparing a family-based smoking cessation intervention with an individual-based smoking cessation intervention. In our study, results showed the family involvement in the smoking cessation interventions was not effective as it would be. In addition, compared with interventions focusing on family-based smoking cessation interventions, results in this study showed that interventions focusing on smokers were more effective for them to quit smoking, however, previous studies showed that no differences existed between smokers-based and family-based smoking cessation interventions. In the study conducted by McBride et al., (2004), the intent-to-treat analyses showed no significant difference was found at any followup time among the three female smoker groups (usual care, female smokers only, or partner-assisted groups) regarding the reports of abstinence. McIntyre-Kingsolver et al., (1986) also found that no significant differences between spouse involved intervention and smoker-based intervention on the smoking cessation rates due to spouse training at any assessment point. Same result was found in Nyborg and Nevid's (1986) study, which showed that although abstinence posttreatment was more frequent among couples in therapist-administered treatment, no significant differences were noticed between couples and individual training approaches.
Possible reasons for family-based smoking cessation interventions not being effective as smokers-based interventions may derive from: 1) more difficulties existing in the family-based training, and 2) challenges to get mutual support during the smoking cessation maintenance period. First, compared with smokersbased interventions, family-based interventions required more work to be done to be effective. Intervention plans which are specifically designed for smokers' non-smoke family members are needed to increase family support. Accordingly, extra staff support and cost related to the non-smoker family members interventions are required. Second, although interventions are implemented aiming to increase family support for Chinese American smokers to quit smoking, sometimes, it may turn out to be ineffective and unhelpful for them to quit smoking. For example, knowing the harm of secondhand smoking, Chinese American smokers' family members may blame the smokers for smoking instead of supporting them to quit. Thus, techniques directed at enhancing social support during the maintenance period need to be explored in working with smoking family members (Nyborg and Nevid, 1986).
As a systematic review and meta-analysis study, this research has some limitations. First, as noticed in the funnel plot, outliners are distributed at the bottom of the plot, this may indicate some systematic bias related to the publication bias. Like it was mentioned in other research (Murad et al., 2018), studies with significant results, published in English language, published quickly, and cited frequently are more likely to be found in the data search process. Accordingly, they are more likely to be included in the systematic review and meta-analysis. This may lead to the publication bias which further impacts the data analysis results. Second, some studies included in this study had a not sufficient PEDro score or MINORS score, which means the quality of the studies are fair. This may impact the meta-analysis result. However, since few studies had been conducted on Chinese American smokers' smoking cessation, and a small sample size was noticed in the subgroup analysis, excluding those studies could result in sample bias in the analysis. Thus, the insufficient strength of evidence included in this review should not be interpreted as evidence that the interventions are not effective but, rather, as encouragement for additional research before effectiveness can be established.
In conclusions, this study examined the effects of smoking cessation interventions on Chinese American smokers quit smoking rates. Results showed that compared to the control group, the group that received interventions on smoking cessation had a significantly increased smoking cessation rate. Furthermore, subgroup analysis showed individual-based, NRT outreach interventions conducted in person with smokers seemed to be effective. This study provided evidence for health care providers to design appropriate and effective smoking cessation interventions to be used in Chinese American smokers. More culturally sensitive and effective interventions are needed to help Chinese American smokers to quit smoking.