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RESEARCH |
Eliseo J. Pérez-Stable is with the Division of General Internal Medicine, Department of Medicine, University of California, San Francisco. Amelie Ramirez is with the Center for Cancer Control Research, Baylor College of Medicine, Waco, Tex. Roberto Villareal is with the Department of Family Medicine, University of Texas Health Science Center, San Antonio. Gregory A. Talavera is with the Division of Health Promotion, School of Public Health, San Diego State University, San Diego, Calif. Edward Trapido is with the Department of Epidemiology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Fla. Lucina Suarez is with the Texas Department of Health, Austin. José Marti is with the Department of Surgery, Brookdale Hospital Medical Center, Brooklyn, NY. Alfred McAlister is with the Center for Health Promotion Research and Development, University of Texas–Houston Health Science Center. All of the authors are with the National Hispanic Leadership Initiative on Cancer: En Acción.
Correspondence: Requests for reprints should be sent to Eliseo Pérez-Stable, MD, 400 Parnassus Ave, Room A-405, San Francisco, CA 94143-0320 (e-mail: eliseops{at}medicine.ucsf.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. This study sought to compare smoking behavior among Latino men and women from different countries of origin.
Methods. A telephone-administered survey was conducted in 8 cities with Latino men and women of different national origin living in census tracts with at least 70% Latino individuals.
Results. A total of 8882 participants completed the survey; 53% were women. The average age of respondents was 44 years; 63% were foreign-born, and 59% preferred Spanish for the interview. Current smoking was more prevalent among men (25.0%, 95% confidence interval [CI] = 23.7, 26.3) than among women (12.1%, 95% CI = 11.1, 13.0). Smoking rates were not significantly different by national origin among men, but Puerto Rican women had higher rates of smoking than other women. Central American men and women had the lowest smoking rates. Foreign-born respondents were less likely to be smokers (odds ratio [OR] = 0.77, 95% CI = 0.66, 0.90) than US-born respondents, and respondents with 12 years or less of education had an increased odds of smoking (OR = 1.17, 95% CI = 1.01, 1.35). High acculturation was associated with more smoking in women (OR = 1.12, 95% CI = 1.00–1.25) and less smoking in men (OR = 0.86, 95% CI = 0.78–0.95). Puerto Rican and Cuban respondents were more likely to be current smokers and to smoke more than 20 cigarettes per day.
Conclusions. Older, US-born, and more-educated respondents were less likely to be current smokers. Respondents of Puerto Rican and Cuban origin were more likely to smoke. Acculturation has divergent effects on smoking behavior by sex.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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The level of acculturation, as measured by short language-based scales, is an important predictor of smoking behavior among US Latinos of Mexican and Central American origin.7,8 These data suggest that smoking behavior among Latinos becomes increasingly similar to that among Whites with increasing levels of acculturation; as a consequence, smoking may become a more serious problem for Latinos as their acculturation increases. Given current smoking trends among Latino youths and the observed effects of acculturation on smoking, there is appropriate concern that tobacco-related disease morbidity among Latinos may increase.9,10
Latino smokers report that they smoke an average of 8 cigarettes per day (women) and 12 cigarettes per day (men). These figures compare with an average of 19.1 and 23.4 cigarettes per day reported by White women and men, respectively.1 Although a smaller proportion of highly acculturated Latino men smoke, they report smoking a larger number of cigarettes per day than less-acculturated Latino men.7,11 Among Latino women, an increased level of acculturation is associated with a higher rate of smoking and, among smokers, with a larger number of cigarettes smoked per day. Latino smokers may underreport their daily consumption of cigarettes to some extent, but biochemical studies support the self-report data that Latinos smoke fewer cigarettes per day than Whites.12–14 These observations have important implications for cessation strategies, because light smokers are more likely to quit smoking successfully with appropriate motivational messages and self-help methods.15
As part of the National Hispanic Leadership Initiative on Cancer: En Acción program, we conducted a survey of Latino adults to examine cigarette smoking behavior.16 Our objective was to evaluate smoking rates, smoking behavior, and the proportion of former smokers by national origin group and demographic predictors. This is the first study to compare smoking rates in a large sample of Latinos from 6 major national origin groups.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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The Office of Survey Research at the University of Texas at Austin conducted the telephone survey between November 1993 and April 1994. On the basis of geographic specification of census tracts and zip codes, lists of working residential numbers were purchased and randomly sampled by computer for administration by bilingual staff who were trained to use a computer-assisted telephone interview system. A household was considered to be eligible if the person answering the telephone self-identified as Latino or Hispanic on screening questions. Within a given household, the adult (18 years or older) who was eligible under the quota sampling requirement and had most recently celebrated a birthday (if more than 1 person met the qualifications) was invited to respond to the survey. Stratified quota sampling defined 4 groups by sex and age: men younger than 40 years and 40 years or older and women younger than 40 years and 40 years or older. The maximum number of respondents in each group within each city was 300. Selection of interviewees was determined by agreement to participate in the survey; when a cell was filled, no additional surveys were conducted in that specific stratum in that city. We selected the age and sex quotas to allow us to identify and compare different sectors of the Latino population across (and between) sites.
Questionnaire
The survey instrument used previously administered questions from the NHIS, the Behavioral Risk Factor Survey,17 and the A Su Salud program.18 Variables analyzed for the present report were age, education, birthplace, income category, language use during interview, national origin, a 5-item language-based acculturation scale,19 and 6 questions about cigarette smoking and quitting behavior. The questionnaire was translated from English to Spanish and back-translated, with standard techniques employed to ensure accuracy and use of culturally appropriate words.20 The survey instrument was pretested by telephone in San Antonio and San Francisco, and minor modifications were made before implementation.
Bilingual and bicultural interviewers were selected to represent each of the 4 major Latino population groups surveyed. The interviewers underwent an average of 9 hours of training, and about 10% percent of their calls were validated. The Spanish-language survey took an average of 27 minutes to administer; the English version took an average of 24 minutes.
Data Analysis
In this study, we analyzed all data separately by sex. We grouped age, education, and income distributions in categories. Overall smoking rates were age-adjusted to the 1990 US Latino population by the direct method and are shown with 95% confidence intervals (CIs).21 We constructed multivariate logistic regression models to predict current smoking and smoking more than 20 cigarettes per day. Predictor variables included age (in 5-year intervals), education (>13 years as referent), income (>$25 000 as referent), national origin group (Mexican American as referent), acculturation score (low score, or less acculturated, as referent), and birthplace (United States as referent). Language of interview was highly correlated with acculturation score (r > 0.8) and thus was not included in the multivariate models. Statistical analyses were conducted with SAS.22
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Table 1
shows the distribution of participants by demographic variable and sex. About 67% of respondents self-identified as Mexican American, 63% preferred Spanish for the interview, 65% reported being born in Latin America, 65% reported an annual household income of less than $25 000, and 48% were less acculturated. The average age of the sample was 43.4 (SD = 17.7) years for men and 44.4 (SD = 18) years for women. The average number of years of formal education was 9.8 (SD = 4.6) for men and 9.0 (SD = 4.6) for women. The mean acculturation score was 2.3 (SD = 1.1) for men and 2.1 (SD = 1.1) for women.
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). Nearly 48% of the men and 75% of the women had never smoked cigarettes or had smoked fewer than 100 cigarettes during their lifetime. The ratio of current smokers to ever smokers was slightly higher for women than for men.
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shows smoking rates by national origin group, demographic variable, and site sampled, separately for men and women. Respondents who were 55 years or older were less likely to smoke than those in other age cohorts. There were no substantial differences in smoking rate among Latino men, although Puerto Rican respondents had the highest smoking rate. However, Puerto Rican women were nearly twice as likely to smoke as women of other national origin who responded to the survey. Sex differences were significant for Mexican American, Central American, and Cuban American respondents and generally persisted for the other demographic variables. Income and education did not significantly affect smoking rates among women, but fewer women born in Latin America tended to smoke. Women who used both languages for the interview were more likely to report smoking than those who responded to the survey in Spanish. Less-acculturated men (score of 1 to <2) and more-acculturated women (score of 3 to 5) reported significantly higher smoking rates than their respective counterparts. Comparison of smoking rates by geographic location showed that among women, respondents in New York (Brooklyn) had a significantly higher smoking rate than those in other locations, and those in Brownsville had the lowest rate; among men, respondents in San Antonio had the highest smoking rate and those in San Diego had the lowest.
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). Among smokers, 7.6% of men and 6.8% of women claimed to smoke an average of less than 1 cigarette per day and thus could be considered occasional smokers. The average number of cigarettes per day and the rate of intermittent smokers varied by national origin group and sex. Less-acculturated smokers tended to smoke fewer cigarettes per day, and a smaller proportion smoked 20 or more cigarettes per day. The proportion of Latino current smokers who had heard or read about how to quit smoking in the 3 months preceding their interview was about 60%, with limited variation across demographic variables.
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We used multiple logistic regression analyses to predict current smoking separately by sex (Table 5). Older age, in increments of 5 years, was associated with a significantly decreased likelihood of smoking among men and women. Having a high school education or less was a significant predictor of current smoking in the total sample. Foreign-born Latino respondents were less likely to be current smokers, although for women the decreased likelihood only approached significance. Acculturation predicted current smoking in divergent directions by sex. Less-acculturated men and more-acculturated women were significantly more likely to be current smokers than their counterparts. Compared with Mexican American respondents, Puerto Rican and Cuban respondents were significantly more likely to report current smoking.
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. Among smokers, increasing age in 5-year intervals predicted heavy smoking for men and women. Overall, Latino smokers who were born outside the United States were less likely to be heavy smokers, although the association was not significant for women. On the other hand, education, income, and acculturation were not significant predictors of heavy smoking for men or women. Compared with Mexican American smokers, Puerto Rican and Cuban smokers were significantly more likely to be heavy smokers. |
DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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This study is the first to compare rates among Latinos from the major national origin groups residing in the United States, and the similarities we found support the notion that smoking behavior is influenced by similar factors among Latinos of different backgrounds. Our survey found rates similar to those in the HHANES,2 which showed that Puerto Ricans and Cubans are more likely to smoke and to smoke more heavily than Mexican Americans. Even after adjusting the data for other factors, we found that Puerto Rican and Cuban respondents were significantly more likely to report current smoking, and current smokers were more likely to smoke 20 or more cigarettes per day, than were Mexican American smokers.
The role of education as a predictor of smoking among Latinos has been examined in other studies and has been found to predict less smoking as education increases above high school.4,24 The fact that Latinos have lower educational attainment did not account for the lower rate of cigarette smoking in 2 California surveys.3,25 In an earlier survey of New Mexico Latinos, smoking status was influenced by educational attainment, with the anticipated decrease in smoking as education increased.26
In this study we found that in the overall sample, respondents with lower educational attainment (high school or less) were more likely to smoke cigarettes than those with more education; separate analyses by sex found only nonsignificant, though similar, trends. The association between greater educational attainment and decreased smoking is observed in more-developed countries.27 In the United States, overall smoking rates peak among persons who do not graduate from high school.1 In less-developed countries, such as in most of Latin America, smoking rates are highest among adults with more education, and economic factors lead to much lower smoking rates among persons with limited formal education.27 It appears that as US Latinos, especially women, increase their educational levels, they are less likely to smoke.4 These observations imply that cigarette smoking cessation interventions may have to be tailored by sex for Latinos, given the levels of education among smokers.
In contrast to the confusing pattern that often emerges from the association of education and smoking, almost all surveys among Latino adults have found a lower rate of smoking among less-acculturated groups, especially when language acculturation scales have been used.1,2,7 These findings have been more striking among Latino women than among Latino men. In New Mexico, language preference did not affect smoking status, but in the California survey, respondents in Spanish were only about half as likely to be daily smokers.25,26
In our study, the association of acculturation and smoking had differential effects by sex. More-acculturated Latino men were significantly less likely to smoke cigarettes, whereas less-acculturated women were significantly less likely to smoke. Although the finding among women is consistent with findings from previous surveys, a differential effect by sex has been found less frequently.7 Latino men who were born in Latin America also were less likely to smoke (after adjustment for other predictors); we observed a nonsignificant trend in the same direction among women. Our findings are consistent with a recent analysis of cardiovascular risk factors among Mexican Americans that found increased risk factors in US-born Spanish-speaking persons.28
Latinos consistently report that they smoke fewer cigarettes per day than Whites and African Americans.1 Most surveys have been conducted with Latinos of Mexican background; the limited data available for Cubans and Puerto Ricans indicate that the average number of cigarettes smoked per day and the proportion of heavy smokers are considerably higher than in Latino groups of other national origin, especially among men.1,2 Our data support these observations: Only about one-quarter of Latino smokers reported smoking a pack or more of cigarettes per day. However, we found that Cubans and Puerto Ricans smoked more cigarettes per day than Mexicans and Central Americans.
In fact, the number of cigarettes smoked per day by Latinos is so low as to lead us to question the extent of dependence. The question of whether there are biological differences in the metabolism of nicotine or the susceptibility to addiction that may affect intake of nicotine among Latinos has not been studied. Although studies have shown that serum cotinine levels are consistent with the self-reported number of cigarettes among Mexican American smokers,14,29 concerns have been raised that there is a higher rate of misclassification of smoking status among minority populations compared with Whites.30
In this study, we observed that a small proportion of respondents reported smoking fewer than 1 cigarette per day, even though they responded affirmatively to the question "Do you smoke cigarettes now?" This group of intermittent smokers is proportionally larger than what had been reported in national surveys; the range in those surveys was 2% to 3%.31 Data from the California survey and the 1991 NHIS indicate that among persons who report smoking some of the time, Latinos are more likely than Whites to be defined as never-daily smokers.32,33 In fact, the proportion of never-daily smokers among Latinos in the 1991 NHIS was 17.4%, compared with 3.8% among Whites and 10.8% among African Americans.33
Analyses from the NHANES III reported that 24.3% of Mexican American smokers consumed only 1 to 4 cigarettes in the previous 5 days, compared with 5.5% of White and 6.2% of Black smokers; thus, more than one-quarter of Mexican American smokers had serum cotinine levels that were consistent with nonsmoking.14 Occasional smokers presumably are at greater risk of progressing to daily smoking and developing nicotine dependence, but the risk of major significant adverse health outcomes related to occasional smoking is limited. Observation of lower smoking-related morbidity and mortality among Latinos may be related to the higher proportion of occasional smokers, further decreasing the contribution of smoking as a risk factor.
Our study has several important limitations. First, the sample was selected from high-concentration census tracts in 8 cities and thus the findings are not fully generalizable to all US Latinos. Second, we calculated smoking rates exclusively on the basis of self-reports, and there is evidence that misclassification of smokers as nonsmokers may occur at a higher rate among non-White persons.30 However, the higher proportion of occasional smokers who may not even achieve levels of cotinine consistent with active smoking may have inflated prevalence rates somewhat. Third, we conducted a short telephone survey that covered a broad array of preventive behaviors that are relevant to cancer; we were not able to ask additional questions about quitting behavior, attitudes toward smoking, and other predictor variables.
Our study is the first survey that compares smoking behavior among 6 Latino groups in the United States. Although there are similar prevalence patterns, Puerto Rican respondents stand out as having the highest rates—including a notable narrowing of the differences between the sexes. These data provide evidence that being born in Latin America appears to protect Latinos from smoking, which is consistent with the observation that increased acculturation to the United States leads to a less healthy lifestyle. Level of educational attainment affected smoking behavior in women only. National data on smoking behavior in US Latino men and women will be useful in developing broad smoking cessation interventions that are tailored to specific national groups, are implemented in Spanish, and consider educational differences to maximize their effectiveness.
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Acknowledgments |
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Respondents provided verbal consent at the time of telephone contact. Institutional review boards from each of the collaborating sites approved the interview protocol. Ginny Gildengorin provided valuable assistance in data analysis.
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Footnotes |
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Accepted for publication October 10, 2000.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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