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

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

Addictive Behaviors 34 (2009) 980–983 Contents lists available at ScienceDirect Addictive Behaviors Short communication The relationship between a...

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Addictive Behaviors 34 (2009) 980–983

Contents lists available at ScienceDirect

Addictive Behaviors

Short communication

The relationship between acculturation and knowledge of health harms and benefits associated 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 States sm b ClearWay Minnesota , Two Appletree Square, 8011 34th Avenue South, Suite 400, Minneapolis, MN 55425, United States c Family Centric Health Promotion Program, Communidades Latinas Unidas En Servicio, 720 East Lake Street, Minneapolis, MN 55407, United States d Center for Prevention, Blue Cross Blue Shield of Minnesota, St. Paul, MN 64560, United States

a r t i c l e Keywords: Smoking Acculturation Latino Health Knowledge Beliefs

i n f o

a b s t r a c t Objectives: This study sought to examine the relationship between acculturation and the knowledge of smoking and health and perception of benefits associated with smoking within the Latino population of Minnesota. In addition to standard acculturation measures, this study employed a multidimensional model and measures of acculturation. Methods: A telephone and in-person administered survey was conducted across the state of Minnesota with Latino men and women. Results: A total of 804 participants completed the survey, 54% were men. The average age of respondents was 37 years; 81% were foreign born and 68% completed the interview in Spanish. Knowledge of the relationship between smoking and lung cancer (99%) and heart disease (93%) was high. Acculturated respondents indicate a more refined knowledge of the relationship between smoking and health conditions not related to smoking (poor vision and arthritis). Smokers identify more benefits associated with smoking than do nonsmokers, with gender (male), education (less than high school) and greater acculturation being significant predictors of perceiving benefits. © 2009 Elsevier Ltd. All rights reserved.

1. Introduction This paper evaluates knowledge and beliefs regarding the harms and benefits associated with cigarette smoking in the Latino population. This is useful because an understanding of these issues, particularly for immigrants, can inform norms specific to smoking behavior 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 nonLatino whites (21.9%) (CDC, 2007), but this is an area of concern due to the 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 that smoking behavior, knowledge and beliefs about smoking are related to both gender and acculturation (Bock, Niaura, Neighbors, CarmonaBarros, & Azam, 2005; Maher et al., 2005; Waldron et al., 1988); as

Latinos become more acculturated their smoking behavior becomes more similar to that of non-Latino whites. Where smoking rates for Latino men are similar to rates for non-Latino white men (Maher et al., 2005), the effect of acculturation translates to an increase in the number of cigarettes smoked per day (CDC, 2007; Marin, Perez-Stable, & Marin, 1989). While Latina women are found to have much lower smoking rates than their non-Latino white counterparts (Maher et al., 2005), the relationship between acculturation and smoking behavior is particularly concerning for women (Bock et al., 2005). Findings suggest significant increases in smoking prevalence within Latina women 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

⁎ Corresponding author. Tel.: +1 612 624 9943; fax: +1 612 624 4408. E-mail address: [email protected] (M.L. Constantine). 0306-4603/$ – see front matter © 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2009.05.008

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

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

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 Spanish through a community review process, cognitive interviews as well as principles of translation/back translation. The survey had a 50% response rate and the total number of completed interviews was 804. The data were weighted to account for subject's a priori differential probabilities of selection based on stratum and number of adults living in the household. The post-stratification weight was applied to the person weight to match known population distributions by age and gender of the Latino population in Minnesota based on 2000 Census data. 2.3. Dependent variables The outcomes of interest are respondent knowledge of the relationship between smoking and specific health conditions, and respondent beliefs about potential benefits of smoking. Respondents were asked to identify whether the each of the following health conditions is caused by smoking: lung cancer, heart disease, poor vision and arthritis. Respondents were asked to indicate whether smoking helps a person make friends, provides pleasure, relieves stress and anxiety, helps focus on activities and helps lose weight. 2.4. Independent variables Standard gender, age, marital status and education demographics were included. Assessment of smoking status was based on the CDC's Behavioral Risk Factor Surveillance Survey (BRFSS) definition of current smoker: have ever smoked a cigarette, have smoked at least 100 cigarettes in their life, and now smoke every day or some days. Most tobacco use research with immigrant populations has relied on primary language, years of residence in the US or where born (US or non-US) as proxies for an indication of level of acculturation (Bock et al., 2005; Crespo, Smit, Carter-Pokras, & Anderson, 2001; Maher et al., 2005). As part of this research, a multidimensional conceptualization of community was utilized to assess community integration and acculturation. From this conceptualization two major constructs emerged: cultural fluency and cultural orientation. Both constructs are modeled as indicators of community identification; home country identification and U.S. identification. For this research cultural fluency is defined as acquired knowledge; cultural skills acquired through socialization (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; identification with culture of origin and new culture and participation in community institutions and activities. A total of 17 items were used to assess this range of issues. These 17 items have been reduced to five latent variables, two focused on fluency and three on orientation. Of the two fluency variables, one is focused on US culture and one is focused on home country1. Three variables represent different aspects of cultural orientation; comparison of self to typical white Minnesotan, importance of practicing home country ways in the home and social embedded-ness in Latino community. 3. Analysis

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benefit (1 = benefit). Chi-square and t-tests were used for bivariate comparison of basic socio-demographic characteristics and outcomes, and multivariate logistic regression is used to model predictors of each outcome variable. Predictive values of variables are reported as odds ratios for prediction of correct identification of health condition or perception of benefit. Data were analyzed using the statistical software 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 are male, 71% of respondents are married and overall 39% of the sample has completed high school. A full 68% of respondents completed the interview in Spanish and the sample is predominantly first generation immigrants (81%). The average number of years immigrants have lived in the US is 13. The overall smoking rate is 13.5%; 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% for both smokers and non-smokers. Non-smokers (94%) were more likely to correctly identify smoking as causing heart disease than smokers (87%). Smokers (62%) were better able to identify arthritis and smoking as unrelated than non-smokers (43%). Finally, a high percentage of both non-smokers (78%) and smokers (60%) incorrectly identify 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 of heart disease, gender and education are strong predictors, with males and respondents with less than a high school education much more likely than females and those with a high school education to know of this relationship. Knowledge of the role of smoking in heart disease is negatively associated with smoking; non-smokers are much more likely than smokers (more than 5 times more likely), to correctly

Table 1 Multivariate logistic regression of factors associated with the identification of risks associated with smoking (Odds ratio, 95% Wald confidence limit). Lung Heart disease cancer Smoking status Gender Age Marital Education

Poor vision

Arthritis

0.19 (0.09–0.41)⁎⁎⁎ 0.22 (0.11–0.44)⁎⁎⁎

2.55 2.48 (1.59–4.07)⁎⁎⁎ (1.55–3.98)⁎⁎⁎

0.44 (0.22–0.86)⁎

2.16 1.50 (1.43–3.27)⁎⁎⁎ (1.07–2.10)⁎

Language US born

2.79 5.37 (1.81–4.31)⁎⁎⁎ (3.27–8.83)⁎⁎⁎

Fluency with US culture Fluency with home country culture Comparison to Minnesotan

1.26 (1.04–1.53)⁎ 0.84 (0.71–1.00)⁎

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

Importance of home country ways Social network

1.96 (1.52–2.53) ⁎⁎⁎

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

Binary variables are dummy coded (0,1) with referent non-smoker, male, not married, less than HS education, English interview and born in US. ⁎p b 0.05, ⁎⁎p b 0.01, ⁎⁎⁎p b 0.001.

0.74 (0.61–0.89)⁎⁎

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Table 2 Multivariate logistic regression of factors associated with the perceived benefits of smoking (Odds ratio, 95% Wald confidence limit). Make friends Smoke status Gender Age Marital Education Language US born Fluency with US culture Fluency with home country culture Comparison to Minnesotan Importance of home country ways Socially embedded

Pleasure

Relieve stress/anxiety

2.72 (1.75–4.22)⁎⁎⁎

4.36 (2.83–6.73)⁎⁎⁎

0.51 (0.31–0.85)⁎⁎⁎

Focus

Weight loss

0.35 (0.21–0.60)⁎⁎⁎ 1.02 (1.00–1.03)⁎ 0.55 (0.34–0.88)⁎ 2.17 (1.46–3.22)⁎⁎⁎

2.10 (1.44–3.05)⁎⁎⁎

0.63 (0.51–0.78)⁎⁎⁎

0.61 (0.50–0.75)⁎⁎⁎

1.26 (1.04–1.53)⁎

1.30 (1.08–1.57)⁎⁎

1.03 (1.02–1.05)⁎⁎⁎ 0.58 (0.41–0.82)⁎⁎

1.40 (1.07–1.84)⁎ 0.72 (0.58–0.91)⁎⁎

Binary variables are dummy coded (0,1) with referent non-smoker, male, not married, less than HS education, English interview and born in US. ⁎p b 0.05, ⁎⁎p b 0.01, ⁎⁎⁎p b 0.001.

identify smoking as a cause of heart disease, an indication that this knowledge may be protective. The only acculturation measure that is significant as a predictor of correctly identifying smoking as a cause of heart disease is the importance of practicing home country ways in the home, almost two times more likely to identify the role of smoking in heart disease. Smokers and respondents with at least a high school education are more likely to know poor vision and arthritis are not considered to be caused by smoking. Relative to acculturation measures as predictors, respondents who are born in the US and respondents who are less socially embedded in the Latino community are more likely to know that poor vision and arthritis are not caused by smoking. 4.4. Perception of benefits of smoking There is a significant difference between smokers and nonsmokers identification of benefits to smoking in three areas, with smokers identifying more benefits than non-smokers; smoking provides 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 see smoking as providing pleasure and over 4 times more likely than nonsmokers to see smoking as relieving stress and anxiety (Table 2). Males are twice as likely as females to identify smoking as helping to make friends and improving ability to focus. Older respondents are more likely to identify pleasure and weight loss as benefits than younger respondents, but the effect size is small. Respondents who are not married are more likely than married respondents to identify weight loss and ability to focus as benefits of smoking. Respondents with a high school education or more are twice as likely to think smoking provides pleasure and relieves stress. Respondents who are more fluent with US culture are more likely to identify benefits (pleasure and stress relief) of smoking, whereas respondents who are more fluent with their home country culture identify improved ability to focus as a benefit. Respondents who are less likely to feel they are similar to typical white Minnesotans are also more likely to see smoking as providing pleasure and relieving stress although they are less likely to believe smoking improves ability to focus. Other indicators primary language or where born were not predictive. 5. Discussion A major contribution of the current research is the use of more refined measures of acculturation. While the measures confirm prior research, it should be noted that the primary indicators (primary language, where born, years in US) were not predictive, but the latent

variables did detect differences due to level of acculturation. This study illustrates that specific socio-cultural factors are important to understanding beliefs relative to the harms and benefits of smoking in the Latino population. It has to be pointed out that the distribution of key indicators (place of birth, primary language, length of time living in the US) in this study compared to others is skewed towards a population that is oriented towards home country orientation. This may be supported by the low smoking rate for females (4%) as compared to rates found by other studies in a more acculturated population (11.1%) (CDC, 2006), which could 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 the relationship between smoking and health than non-smokers. This may be attributable to the salience to smokers of the relationship between health and smoking behavior, or it may also be an indicator of a perception within the Latino population, and particularly less acculturated Latinos, of smoking as a behavior that is overall detrimental to most aspects of health. While general population studies find that smokers are as knowledgeable or more knowledgeable than non-smokers relative to the relationship between smoking and heart disease (Weinstein, Slovic, Waters, & Gibson, 2004), the finding of this study that Latino smokers are so much less likely than Latino non-smokers to understand the role of smoking in heart disease is troubling, particularly as coronary artery disease is the leading cause of death for Latinos in the U.S. (USDHHS, 1998). Differences between gender and level of acculturation relative to beliefs about the health effects of smoking as well as perceived benefits of smoking are both related to actual smoking behavior. This knowledge may help guide future community education efforts within the Latino population. The finding that smokers are less aware of the link between smoking and heart disease than non-smokers indicates a need to increase educational efforts around this issue for Latinos. The gender differences relative to smoking and making friends and improving ability to focus is not surprising given the cultural stigma attached to women smoking in many Latino cultures. Based on our findings from earlier work in the Latino community, smoking is considered a very social activity among male peers. Therefore, greater orientation towards home country culture and social integration within the community and may serve to reinforce smoking behavior among Latino men. The stigma associated with smoking for women is reflected in the differences of perception of benefits between men and women. Cessation programs should provide services for individuals or for groups of women alone, but not necessarily for mixed groups of men and women. Acknowledgments Funding for this project was provided by ClearWay MinnesotaSM (RC 2005_0019). The contents of this manuscript are solely the

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

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

Appendix A

References

Fluency 1 Scale Fluency with U.S. culture How well do you understand the Boston tea party? How well do you understand the legend of Paul Bunyan and babe the blue ox? How well do you understand U.S. sporting events such as the Super Bowl or Stanley Cup playoffs? How well do you understand U.S. Holidays such as thanksgiving and 4th of July? Fluency 2 Scale Fluency with home country culture If you attended a wedding or funeral based on bfillN traditions, how well 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 or different are you in terms of the music you listen to? Comparing yourself to a typical white Minnesotan, how similar or different are you in terms of the expressions you use when you speak (slang)? Comparing yourself to a typical white Minnesotan, how similar or different are you in terms of the food you eat? Comparing yourself to a typical white Minnesotan, how similar or different are you in terms of the sports or sporting teams you follow? Orientation 2 Scale Importance of maintaining home country ways in home How important do you feel it is to keep in touch with or learn about your fill ethnic or cultural background? How important is it to you that bfillN ways are practiced in your home? Do you think you are similar or different to people who live in bfillN (country) How strongly do you identify with your fill background? Orientation 3 Scale Ethnicity of Social Network How many of your close friends are from the same ethnic background as you? How many of your casual friends or acquaintances are from the same ethnic background as you? How many of your neighbors are from the same ethnic background as you?

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