Addictive Behaviors 34 (2009) 980–983

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Addictive Behaviors

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The relationship between acculturation and knowledge of health harms and benefitsassociated with smoking in the Latino population of Minnesota

Melissa L. Constantine a,⁎, Todd H. Rockwood a, Barbara A. Schillo b, Jose William Castellanos c,Steven S. Foldes d, Jessie E. Saul b

a Division of Health Policy and Management, School of Public Health, University of Minnesota, C312 Mayo Memorial Building, 420 Delaware Street, SE, MMC 729,Minneapolis, MN 55455, United Statesb ClearWay Minnesotasm, Two Appletree Square, 8011 34th Avenue South, Suite 400, Minneapolis, MN 55425, United Statesc Family Centric Health Promotion Program, Communidades Latinas Unidas En Servicio, 720 East Lake Street, Minneapolis, MN 55407, United Statesd Center for Prevention, Blue Cross Blue Shield of Minnesota, St. Paul, MN 64560, United States

⁎ Corresponding author. Tel.: +1 612 624 9943; fax:E-mail address: cons0026@umn.edu (M.L. Constanti

0306-4603/$ – see front matter © 2009 Elsevier Ltd. Adoi:10.1016/j.addbeh.2009.05.008

a b s t r a c t

a r t i c l e i n f o

Keywords:

SmokingAcculturationLatinoHealthKnowledgeBeliefs

Objectives: This study sought to examine the relationship between acculturation and the knowledge ofsmoking and health and perception of benefits associated with smoking within the Latino population ofMinnesota. In addition to standard acculturation measures, this study employed a multidimensional modeland measures of acculturation.Methods: A telephone and in-person administered survey was conducted across the state of Minnesota withLatino men and women.

Results: A total of 804 participants completed the survey, 54% were men. The average age of respondents was37 years; 81% were foreign born and 68% completed the interview in Spanish. Knowledge of the relationshipbetween smoking and lung cancer (99%) and heart disease (93%) was high. Acculturated respondentsindicate a more refined knowledge of the relationship between smoking and health conditions not related tosmoking (poor vision and arthritis). Smokers identify more benefits associated with smoking than do non-smokers, with gender (male), education (less than high school) and greater acculturation being significantpredictors of perceiving benefits.

© 2009 Elsevier Ltd. All rights reserved.

1. Introduction

This paper evaluates knowledge and beliefs regarding the harmsand benefits associated with cigarette smoking in the Latinopopulation. This is useful because an understanding of these issues,particularly for immigrants, can inform norms specific to smokingbehavior as well as benefit smoking prevention and cessation efforts(Waldron et al., 1988; Steptoe et al., 2002).

Nationally, Latinos report lower smoking rates (16.2%) than non-Latinowhites (21.9%) (CDC, 2007), but this is an area of concern due tothe targeted marketing of tobacco products to the Latino community(CDC, 1998; Laws, Whitman, Bowser, & Krech, 2002; Portugal et al.,2004). Within the Latino population there is initial evidence thatsmoking behavior, knowledge and beliefs about smoking are relatedto both gender and acculturation (Bock, Niaura, Neighbors, Carmona-Barros, & Azam, 2005; Maher et al., 2005; Waldron et al., 1988); as

+1 612 624 4408.ne).

ll rights reserved.

Latinos become more acculturated their smoking behavior becomesmore similar to that of non-Latino whites. Where smoking rates forLatinomen are similar to rates for non-Latinowhitemen (Maher et al.,2005), the effect of acculturation translates to an increase in thenumber of cigarettes smoked per day (CDC, 2007; Marin, Perez-Stable,& Marin, 1989). While Latina women are found to have much lowersmoking rates than their non-Latino white counterparts (Maher et al.,2005), the relationship between acculturation and smoking behavioris particularly concerning for women (Bock et al., 2005). Findingssuggest significant increases in smoking prevalence within Latinawomen as acculturation to U.S. norms increases (Abraido-Lanza, Chao,& Florez, 2005; Marin et al., 1989; Perez-Stable et al., 2001).

2. Methods

2.1. Sampling design

A community based participatory research model guided thedesign and administration of this study. The sample for this study wasa surnamed screened listed frame, in which telephone and face-to-face interviews were conducted. Eligible participants were individuals

Table 1Multivariate logistic regression of factors associated with the identification of risksassociated with smoking (Odds ratio, 95% Wald confidence limit).

Lungcancer

Heart disease Poor vision Arthritis

Smoking status 0.19(0.09–0.41)⁎⁎⁎

2.55(1.59–4.07)⁎⁎⁎

2.48(1.55–3.98)⁎⁎⁎

Gender 0.22(0.11–0.44)⁎⁎⁎

AgeMaritalEducation 0.44

(0.22–0.86)⁎2.16(1.43–3.27)⁎⁎⁎

1.50(1.07–2.10)⁎

LanguageUS born 2.79

(1.81–4.31)⁎⁎⁎5.37(3.27–8.83)⁎⁎⁎

Fluency with US cultureFluency with homecountry culture

Comparison toMinnesotan 1.26(1.04–1.53)⁎

Importance of homecountry ways

1.96(1.52–2.53) ⁎⁎⁎

0.84(0.71–1.00)⁎

Social network 0.74

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who self identified as Latino or who had a Latino heritage, e.g.parents/grandparents born in Central or South America.

2.2. Instrument

The survey instrument was translated from English into Spanishthrough a community review process, cognitive interviews as well asprinciples of translation/back translation. The survey had a 50%response rate and the total number of completed interviews was 804.

The datawereweighted to account for subject's a priori differentialprobabilities of selection based on stratum and number of adults livingin the household. The post-stratification weight was applied to theperson weight to match known population distributions by age andgender of the Latino population in Minnesota based on 2000 Censusdata.

2.3. Dependent variables

The outcomes of interest are respondent knowledge of the rela-tionship between smoking and specific health conditions, andrespondent beliefs about potential benefits of smoking. Respondentswere asked to identify whether the each of the following healthconditions is caused by smoking: lung cancer, heart disease, poorvision and arthritis. Respondents were asked to indicate whethersmoking helps a person make friends, provides pleasure, relievesstress and anxiety, helps focus on activities and helps lose weight.

2.4. Independent variables

Standard gender, age, marital status and education demographicswere included. Assessment of smoking status was based on the CDC'sBehavioral Risk Factor Surveillance Survey (BRFSS) definition ofcurrent smoker: have ever smoked a cigarette, have smoked at least100 cigarettes in their life, and now smoke every day or some days.

Most tobacco use research with immigrant populations has reliedon primary language, years of residence in the US or where born (USor non-US) as proxies for an indication of level of acculturation (Bocket al., 2005; Crespo, Smit, Carter-Pokras, & Anderson, 2001; Maher etal., 2005). As part of this research, a multidimensional conceptualiza-tion of community was utilized to assess community integration andacculturation. From this conceptualization two major constructsemerged: cultural fluency and cultural orientation. Both constructsare modeled as indicators of community identification; home countryidentification and U.S. identification. For this research cultural fluencyis defined as acquired knowledge; cultural skills acquired throughsocialization (e.g. language(s), sense of nationality and shared history,knowledge of traditions, religious and appropriate social behaviors).Cultural orientation is defined as attitudes and behavior; identifica-tion with culture of origin and new culture and participation incommunity institutions and activities. A total of 17 items were used toassess this range of issues. These 17 items have been reduced to fivelatent variables, two focused on fluency and three on orientation. Ofthe two fluency variables, one is focused on US culture and one isfocused on home country1. Three variables represent different aspectsof cultural orientation; comparison of self to typical white Minneso-tan, importance of practicing home country ways in the home andsocial embedded-ness in Latino community.

3. Analysis

Outcome variables are dichotomized (0,1) for knowledge of eachhealth condition listed (1=correct identification), and each listed

1 For immigrants this refers to the country they immigrated from. For Latinos born inthe US this refers to the country their parents or grandparents immigrated from or inthe case of multiple generations in the US Latino Culture.

benefit (1=benefit). Chi-square and t-tests were used for bivariatecomparison of basic socio-demographic characteristics and outcomes,andmultivariate logistic regression is used tomodel predictors of eachoutcome variable. Predictive values of variables are reported as oddsratios for prediction of correct identification of health condition orperception of benefit. Data were analyzed using the statisticalsoftware SAS© 9.1 and a significance level of .05 or less is used.

4. Results

4.1. Demographics

The study achieved a 50% response rate (n=805) (AAPOR RR1,2008). Over half (55%)were in-person interviews. The average age is 37,54%of respondents aremale, 71%of respondents aremarriedandoverall39% of the sample has completed high school. A full 68% of respondentscompleted the interview in Spanish and the sample is predominantlyfirst generation immigrants (81%). The average number of yearsimmigrants have lived in the US is 13. The overall smoking rate is13.5%; within males it is 22% and within females it is 4%.

4.2. Knowledge of smoking-related health conditions

Knowledge that smoking causes lung cancer was high, over 99% forboth smokers and non-smokers. Non-smokers (94%) were more likelyto correctly identify smoking as causing heart disease than smokers(87%). Smokers (62%) were better able to identify arthritis andsmoking as unrelated than non-smokers (43%). Finally, a highpercentage of both non-smokers (78%) and smokers (60%) incorrectlyidentify poor vision as being caused by smoking.

4.3. Predictors of knowledge of smoking related health harms

As shown in Table 1, relative to knowledge of smoking as a cause ofheart disease, gender and education are strong predictors, with malesand respondents with less than a high school education much morelikely than females and those with a high school education to know ofthis relationship. Knowledge of the role of smoking in heart disease isnegatively associated with smoking; non-smokers are much morelikely than smokers (more than 5 times more likely), to correctly

(0.61–0.89)⁎⁎

Binary variables are dummy coded (0,1) with referent non-smoker, male, not married,less than HS education, English interview and born in US.⁎pb0.05, ⁎⁎pb0.01, ⁎⁎⁎pb0.001.

Table 2Multivariate logistic regression of factors associated with the perceived benefits of smoking (Odds ratio, 95% Wald confidence limit).

Make friends Pleasure Relieve stress/anxiety Focus Weight loss

Smoke status 2.72 (1.75–4.22)⁎⁎⁎ 4.36 (2.83–6.73)⁎⁎⁎Gender 0.51 (0.31–0.85)⁎⁎⁎ 0.35 (0.21–0.60)⁎⁎⁎Age 1.02 (1.00–1.03)⁎ 1.03 (1.02–1.05)⁎⁎⁎Marital 0.55 (0.34–0.88)⁎ 0.58 (0.41–0.82)⁎⁎Education 2.17 (1.46–3.22)⁎⁎⁎ 2.10 (1.44–3.05)⁎⁎⁎LanguageUS bornFluency with US culture 0.63 (0.51–0.78)⁎⁎⁎ 0.61 (0.50–0.75)⁎⁎⁎Fluency with home country culture 1.40 (1.07–1.84)⁎Comparison to Minnesotan 1.26 (1.04–1.53)⁎ 1.30 (1.08–1.57)⁎⁎ 0.72 (0.58–0.91)⁎⁎Importance of home country waysSocially embedded

Binary variables are dummy coded (0,1) with referent non-smoker, male, not married, less than HS education, English interview and born in US.⁎pb0.05, ⁎⁎pb0.01, ⁎⁎⁎pb0.001.

982 M.L. Constantine et al. / Addictive Behaviors 34 (2009) 980–983

identify smoking as a cause of heart disease, an indication that thisknowledge may be protective. The only acculturation measure that issignificant as a predictor of correctly identifying smoking as a cause ofheart disease is the importance of practicing home country ways inthe home, almost two timesmore likely to identify the role of smokingin heart disease.

Smokers and respondents with at least a high school education aremore likely to know poor vision and arthritis are not considered to becaused by smoking. Relative to acculturation measures as predictors,respondents who are born in the US and respondents who are lesssocially embedded in the Latino community are more likely to knowthat poor vision and arthritis are not caused by smoking.

4.4. Perception of benefits of smoking

There is a significant difference between smokers and non-smokers identification of benefits to smoking in three areas, withsmokers identifying more benefits than non-smokers; smokingprovides pleasure (42%/21%), relieves stress and anxiety (57%/24%),and helps focus on activities (16%/10%).

4.5. Predictors of perception of benefits of smoking

Smokers are almost 3 times more likely than non-smokers to seesmoking as providing pleasure and over 4 times more likely than non-smokers to see smoking as relieving stress and anxiety (Table 2).Males are twice as likely as females to identify smoking as helping tomake friends and improving ability to focus. Older respondents aremore likely to identify pleasure and weight loss as benefits thanyounger respondents, but the effect size is small. Respondents whoare not married are more likely than married respondents to identifyweight loss and ability to focus as benefits of smoking. Respondentswith a high school education or more are twice as likely to thinksmoking provides pleasure and relieves stress.

Respondents who are more fluent with US culture are more likely toidentify benefits (pleasure and stress relief) of smoking, whereasrespondents who are more fluent with their home country cultureidentify improved ability to focus as a benefit. Respondentswho are lesslikely to feel they are similar to typical whiteMinnesotans are alsomorelikely to see smoking as providing pleasure and relieving stress althoughthey are less likely to believe smoking improves ability to focus. Otherindicators primary language or where born were not predictive.

5. Discussion

A major contribution of the current research is the use of morerefined measures of acculturation. While the measures confirm priorresearch, it should be noted that the primary indicators (primarylanguage, where born, years in US) were not predictive, but the latent

variables did detect differences due to level of acculturation. Thisstudy illustrates that specific socio-cultural factors are important tounderstanding beliefs relative to the harms and benefits of smoking inthe Latino population.

It has to be pointed out that the distribution of key indicators (placeof birth, primary language, length of time living in the US) in this studycompared to others is skewed towards a population that is orientedtowards home country orientation. This may be supported by the lowsmoking rate for females (4%) as compared to rates found by otherstudies in a more acculturated population (11.1%) (CDC, 2006), whichcould be seen as support for the finding that as “Americanization”occurs in Latina women the smoking rate increases.

Generally, smokers demonstrate a more refined knowledge of therelationshipbetween smokingandhealth thannon-smokers. Thismaybeattributable to the salience to smokers of the relationship between healthand smoking behavior, or it may also be an indicator of a perceptionwithin the Latino population, and particularly less acculturated Latinos, ofsmoking as a behavior that is overall detrimental to most aspects ofhealth. While general population studies find that smokers are as know-ledgeable or more knowledgeable than non-smokers relative to therelationship between smoking and heart disease (Weinstein, Slovic,Waters, & Gibson, 2004), the finding of this study that Latino smokers areso much less likely than Latino non-smokers to understand the role ofsmoking in heart disease is troubling, particularly as coronary arterydisease is the leading cause of death for Latinos in the U.S. (USDHHS,1998).

Differences between gender and level of acculturation relative tobeliefs about the health effects of smoking as well as perceived benefitsof smoking are both related to actual smoking behavior. This knowledgemay help guide future community education efforts within the Latinopopulation. The finding that smokers are less aware of the link betweensmoking and heart disease than non-smokers indicates a need toincrease educational efforts around this issue for Latinos.

The gender differences relative to smoking and making friends andimproving ability to focus is not surprising given the cultural stigmaattached to women smoking in many Latino cultures. Based on ourfindings from earlier work in the Latino community, smoking is con-sidered a very social activity among male peers. Therefore, greaterorientation towards home country culture and social integration withinthe community and may serve to reinforce smoking behavior amongLatinomen. The stigmaassociatedwith smoking forwomen is reflected inthe differences of perception of benefits between men and women.Cessation programs should provide services for individuals or for groupsofwomenalone, but not necessarily formixedgroupsofmenandwomen.

Acknowledgments

Funding for this project was provided by ClearWay MinnesotaSM

(RC 2005_0019). The contents of this manuscript are solely the

983M.L. Constantine et al. / Addictive Behaviors 34 (2009) 980–983

responsibility of the authors and do not necessarily represent theofficial views of ClearWay Minnesota.

Appendix A

Fluency 1 Scale Fluency with U.S. cultureHow well do you understand the Boston tea party?How well do you understand the legend of Paul Bunyan and babethe blue ox?Howwell do you understand U.S. sporting events such as the SuperBowl or Stanley Cup playoffs?How well do you understand U.S. Holidays such as thanksgivingand 4th of July?

Fluency 2 Scale Fluency with home country cultureIf you attended awedding or funeral based on bfillN traditions, howwell would you understand what is going on?I understand bfillN traditions very well

Orientation 1 Scale Comparison of self to a “typical white Minnesotan”for behaviors

Comparing yourself to a typical white Minnesotan, how similar ordifferent are you in terms of the music you listen to?Comparing yourself to a typical white Minnesotan, how similar ordifferent are you in terms of the expressions you use when youspeak (slang)?Comparing yourself to a typical white Minnesotan, how similar ordifferent are you in terms of the food you eat?Comparing yourself to a typical white Minnesotan, how similar ordifferent are you in terms of the sports or sporting teams you follow?

Orientation 2 Scale Importance of maintaining home country ways inhome

How important do you feel it is to keep in touchwith or learn aboutyour fill ethnic or cultural background?How important is it to you that bfillN ways are practiced in yourhome?Do you think you are similar or different to peoplewho live in bfillN(country)How strongly do you identify with your fill background?

Orientation 3 Scale Ethnicity of Social NetworkHowmany of your close friends are from the same ethnic backgroundas you?How many of your casual friends or acquaintances are from thesame ethnic background as you?Howmany of your neighbors are from the same ethnic backgroundas you?

All are scored so that a low score indicates US and a high scoreindicators home country.

References

AAPOR. Standard Definitions. Final Dispositions of Case Codes and Outcome Rates forSurveys. Revised 2008. Available from http://www.aapor.org/uploads/Standard_Definitions_04_08_Final.pdf

Abraido-Lanza, A. F., Chao, M. T., & Florez, K. R. (2005). Do healthy behaviors declinewith greater acculturation?: Implications for the Latino mortality paradox. SocialScience and Medicine, 61, 1243−1255.

Bock, B. C., Niaura, R. S., Neighbors, C. J., Carmona-Barros, R., & Azam, M. (2005).Differences between Latino and non-Latino White smokers in cognitive andbehavioral characteristics relevant to smoking cessation. Addictive Behaviors, 30,711−724.

Centers for Disease Control and Prevention (1998). Tobacco use among U.S. racial/ethnic minority groups. Hispanics and Tobacco Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_1998/sgr-min-hsp.htm

Centers for Disease Control and Prevention (2006). Tobacco use among adults—UnitedStaes, 2005. Morbidity and Mortality Weekly Report, 55(42), 1145−1148.

Centers for Disease Control and Prevention (2007). Smoking and Tobacco Use. Fact sheet.(cited January14, 2009)Available from:http://www.cdc.gov/tobacco/data_statistics/fact_sheets/populations/hispanics_tobacco.htm

Crespo, Carlos J., Smit, Ellen, Carter-Pokras, O., & Anderson, R. (2001). Acculturation andleisure-time physical inactivity in Mexican American adults: Results from NHANESIII, 1988–1994. American Journal of Public Health, 91(8), 1254−1257.

Laws, M. B., Whitman, J., Bowser, D. M., & Krech, L (2002). Tobacco availability and pointof sale marketing in demographically contrasting districts of Massachusetts. To-bacco Control, 11, ii71−ii73.

Maher, J. E., Boysun, M. J., Rohde, K., Stark, M. J., Pizacani, B. A., Dilley, J., et al. (2005). AreLatinos really less likely to be smokers? Lessons from Oregon. Nicotine and TobaccoResearch, 7(2), 283−287.

Marin, Gerado, Perez-Stable, Elisio, & Marin, B. V. (1989). Cigarette smoking among SanFrancisco Hispanics: The role of acculturation and gender. American Journal of PublicHealth, 79(2), 196−198.

Perez-Stable, Elisio J., Ramirez, Amelie, Villareal, R., Talavera, G. A., Trapido, E., Suarez, L.,et al. (2001). Cigarette smoking behavior among US Latino men and women fromdifferent countries of origin. American Journal of Public Health, 90(9), 1424−1430.

Portugal, Cecilia, Cruz, Tess Boley, Espinoza, L., Romero, M., & Baezconde-Garbanati, L.(2004). Countering tobacco industry sponsorship of Hispanic/Latino organizationsthrough policy adoption: A case study. Health Promotion Practice, 5(3), 143S−156S.

Steptoe, A., Wardle, J., Cui, W., Baban, A., Glass, K., Pelzer, K., et al. (2002). Aninternational comparison of tobacco smoking, beliefs and risk awareness inuniversity students from 23 countries. Addiction, 97, 1561−1571.

U.S. Department of health and human services, CDC (1998). Tobacco Use Among U.S.Racial/Ethnic Minority Groups–African Americans, American Indians and AlaskaNatives, Asian Americans and Pacific Islanders, and Hispanics: A Report of the SurgeonGeneral. (cited January 14, 2009) Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_1998/index.htm

Waldron, I., Bratelli, G., Carriker, L., Sung, W., Vogeli, C., & Waldman, E. (1988). Genderdifferences in tobacco use in Africa, Asia, the Pacific, and Latin America. SocialScience Medicine, 27(11), 1269−1275.

Weinstein, N. D., Slovic, P., Waters, E., & Gibson, G. (2004). Public understanding of theillness caused by cigarette smoking. Nicotine and Tobacco Research, 6(2), 349−355.