University of California Peer Reviewed Title: Acculturation and smoking patterns among Hispanics - A review Author: Bethel, J W Schenker, Marc B, University of California, Davis Publication Date: 08-01-2005 Publication Info: Postprints, UC Davis Permalink: http://escholarship.org/uc/item/7db0s7hj Additional Info: The published version of this article is available at: www.elsevier.com/locate/amepre Keywords: smoking, hispanic, acculturation Abstract: Objective: To conduct a systematic review of published studies investigating the association of acculturation and smoking patterns among Hispanic men and women in the United States. Methods: Online bibliographic databases were searched from 1985 to 2003 using three key search terms. The methodology and findings of all retrieved articles were critically evaluated. Data were extracted from each article regarding study population, study methods, exposure assessment, outcomes measured, acculturation measures used, and results. Results: The literature search identified 78 articles from MEDLINE, PubMed, and PsychINFO databases; of these, 11 studies met the inclusion criteria. Seven regional studies based in the western United States and four nationwide studies were included in the review. Seven studies used formal acculturation scales, three used language spoken, and one used language spoken and country of birth to indicate acculturation status. Nine studies showed a positive association between acculturation and smoking among women, and one study involving men showed a negative association. Conclusions: The findings suggest that the association of acculturation and smoking is gender-specific. In this instance, increased smoking prevalence with increased acculturation is consistently observed among Hispanic women but not among men. As Hispanic women acculturate, their cigarette smoking may increase because their behavior becomes more strongly influenced by the norms and practices of the dominant group than among men. Immigrant- and gender-specific public health interventions need to be designed to combat the increase in smoking rates among Hispanics in the United States. (c) 2005 American journal of Preventive Medicine eScholarship provides open access, scholarly publishing services to the University of California and delivers a dynamic research platform to scholars worldwide. 1 THE ASSOCIATION BETWEEN ACCULTURATION AND SMOKING PATTERNS AMONG HISPANICS: A REVIEW Jeffrey W. Bethel, Marc B. Schenker, MD, MPH Department of Public Health Sciences, University of California, Davis, California Correspondence and reprint requests: Marc B. Schenker, MD, MPH Professor and Chair, Department of Public Health Sciences University of California One Shields Avenue, TB 168 Davis, CA 95616-8638 Phone: 530-752-5676 Fax: 530-752-3239 Email: mbschenker@ucdavis.edu Word count: 2,470 Number of pages: 9 (text only) Number of tables: 3 Bethel-smoking_v8.doc 2 ABSTRACT Objective To conduct a systematic review of published studies investigating the association of acculturation and smoking patterns among Hispanic men and women in the United States. Methods Online bibliographic databases were searched from 1985 to 2003 using three key search terms. The methodology and findings of all retrieved articles were critically evaluated. Data were extracted from each article regarding study population, study methods, exposure assessment, outcomes measured, acculturation measures used, and results. Results The literature search identified 78 articles from MEDLINE, PubMed, and PsychINFO databases; of these, eleven studies met the inclusion criteria. Seven regional studies based in the western U.S. and four nationwide studies were included in the review. Seven studies utilized formal acculturation scales, three used language spoken, and one used language spoken and country of birth to indicate acculturation status. Nine studies showed a positive association between acculturation and smoking among women and one study involving men showed a negative association. Conclusion The findings suggest that the association of acculturation and smoking is gender-specific. In this instance, increased smoking prevalence with increased acculturation is consistently observed among Hispanic women but not among men. As Hispanic women acculturate, their cigarette smoking may increase because their behavior becomes more strongly influenced by the norms and practices of the dominant group than among men. Immigrant- and gender-specific public Bethel-smoking_v8.doc 3 health interventions need to be designed to combat the increase in smoking rates among Hispanic in the U.S. Bethel-smoking_v8.doc 4 1 INTRODUCTION 2 Cigarette smoking is the leading cause of preventable death in the United States and produces 3 substantial health-related economic costs to society.1 From 1995-1999, over 440,000 people in 4 the U.S. died from smoking-related causes each year. Among adults, most smoking deaths were 5 from lung cancer (124,813), ischemic heart disease (81,976), and chronic airway obstruction 6 (64,735).1 Estimates show that smoking caused over $150 billion in annual health-related 7 economic losses from 1995-1999 including $81.9 billion in mortality-related productivity and 8 $75.5 billion in excess medical expenditures in 1998.1 9 National and regional surveys have shown that Hispanics have lower smoking rates than non- 10 Hispanic whites. Data from the 2001 National Health Interview Survey (NHIS) show that the 11 overall prevalence of cigarette smoking was significantly lower for Hispanics (16.7%, SD=1.2) 12 than for non-Hispanic whites (24.0%, SD=0.6).2 The percentage of Hispanic men who currently 13 smoked (21.6%, SD=1.9) was lower than the percentage among non-Hispanic white men 14 (25.4%, SD=1.0). However, a wider gap was seen when comparing Hispanic and non-Hispanic 15 white women. The percentage of Hispanic women who currently smoked (11.9%, SD=1.3) was 16 nearly half of the percentage among non-Hispanic white women (22.8%, SD=0.9).2 17 Acculturation to the mainstream U.S. society is a complex, multidimensional phenomenon that 18 has a crucial but poorly understood role in many health behaviors, including smoking.3 The term 19 acculturation refers to changes in values, attitudes, and behaviors experienced by individuals of 20 an ethnic group as a result of continuous interaction with people of a different ethnic group.4-6 21 This acculturation model predicts that smoking patterns of Hispanics would reflect the extent to 22 which they have adopted the smoking norms and practices of the larger society. This suggests 23 that Hispanic smoking rates will eventually equal those of non-Hispanic whites with increasing Bethel-smoking_v8.doc 5 24 levels of acculturation. With more than 35 million Hispanics living in the U.S. (40% are foreign- 25 born), the effect of acculturation on smoking is clearly a public health concern.7 Again, the 26 concept of acculturation is a complex phenomenon which is not fully understood. However, 27 formal scales have been developed and proxy measures used in an attempt to better understand 28 its association with health outcomes and health behaviors. 29 The objectives of this paper are to 1) review published studies investigating the association of 30 acculturation on smoking patterns among Hispanic men and women in the U.S, and 2) examine 31 the acculturation measures used in these studies. 32 33 METHODOLOGY 34 This literature review consisted of studies that examined acculturation and health behaviors of 35 Hispanics in the U.S. Studies under review were initially identified using MEDLINE, PubMed, 36 and PsychINFO database search engines. The three key search terms were smoking, and 37 acculturation or immigration, and Hispanic or Mexican-American or Latino/a. The search terms 38 were limited from 1985 to 2003 but included all journals in the databases. This lower limit was 39 chosen to include articles using data from the Hispanic Health and Nutrition Examination Survey 40 (HHANES) 1982-1984, an important study of Hispanic health in the U.S. This search strategy 41 identified 78 articles that provided data on smoking and acculturation/immigration among 42 Hispanics in the U.S. These articles were examined and final inclusion into the review was 43 determined by 1) English language reference 2) use of an adult study population and 3) 44 examination of smoking rates across acculturation groups using measures based on a validated 45 scale, language preference, country of birth or time (years) living in the U.S. The large 46 percentage of the excluded references did not satisfy the second or third criterion. Bethel-smoking_v8.doc 6 47 RESULTS 48 A total of 26,611 men and women were included in the 11 studies with sample sizes ranging 49 from 76 to 8,882. Three studies analyzed women only and the remaining eight studies analyzed 50 men and women (Table 1). The respondents were predominantly of Mexican origin with a small 51 proportion coming from Puerto Rico, Cuba, Central America, and South America. 52 Approximately 70% of the respondents were drawn from the general U.S. population and the 53 remainder was from western U.S. states including Arizona, California, Colorado, New Mexico, 54 and Texas. All of the studies were cross-sectional in design; eight utilized in-person interviews, 55 two used telephone interviews, and one study used a self-administered survey. All studies were 56 administered in English or Spanish based on the participants’ preference. Seven studies 57 employed formal acculturation scales19,23-31, three used language spoken7-9 and one used 58 language spoken and country of birth10 to indicate acculturation status. The studies using formal 59 acculturation scales reported excellent internal reliability with Cronbach alpha values ranging 60 from 0.75 to 0.96. 61 Smoking rates by study location 62 Current smoking rates ranged from 24.5% to 45.8% in the eight studies involving men and 63 11.5% to 26.1% in the eleven studies involving women (Table 2). The prevalence ratios show 64 that among Hispanics, smoking rates in men were approximately twice as high as rates in women 65 in most studies (Table 2). Among men and women, similar ranges of smoking rates and 66 prevalence ratios were found in studies using nationwide samples and populations in the Western 67 U.S. 68 Smoking rates by acculturation measures 69 1. Proxy measures for acculturation Bethel-smoking_v8.doc 7 70 The association between acculturation and current smoking rates was examined to address the 71 primary objective of the review. Four studies used proxy measures for acculturation including 72 three which used language spoken and one which used country of birth and language spoken. 73 All of these studies analyzed women and three analyzed men and women. A positive association 74 was found between acculturation and smoking in three of the four studies involving women 75 (Table 3). English language use was associated with higher rates of smoking than Spanish 76 language use. Specifically, English-speaking Hispanic women had current smoking rates of over 77 four and two times higher than Spanish-Speaking Hispanic women in studies by Acevedo et al.8 78 and Palinkas et al.9, respectively. In the study by Sundquist and Winkleby11, both Spanish- and 79 English-speaking US-born Hispanic women had a higher age- and education-adjusted smoking 80 prevalence than the Mexican-born women. However, among men, no studies using a proxy 81 measure for acculturation showed an association between language preference and smoking. 82 2. Acculturation Scales 83 Seven studies involved women and utilized formal scales to assess acculturation whereas five 84 studies involved men (and women) and used a formal acculturation scale.12-18 When smoking 85 rates and analytical model results were examined, six of the seven studies involving women 86 showed a positive association between acculturation and smoking (Table 3). An increase in 87 acculturation was consistently associated with higher current smoking rates. Specifically, studies 88 by Cantero et al., Haynes et al., Marin et al., and Perez-Stable et al. found ranges of current 89 smoking rates (from low to high acculturation) of 11.0% to 25.1%, 19.0% to 28.0%, 13.6% to 90 22.6%, and 10.3% to 15.5% among Hispanic women, respectively.12,15,16,18 Coonrod and 91 colleagues found a current smoking prevalence ratio of 3.7 comparing US-oriented and Mexico- 92 oriented Hispanic women.13 Finally, Coreil et al. used logistic regression to find a significant Bethel-smoking_v8.doc 8 93 positive association between acculturation and current smoking status across all age groups of 94 women.14 95 Only one study involving men showed a significant association between acculturation and 96 smoking. Marin et al. found a negative association between acculturation and smoking in which 97 more acculturated men had a lower current age-adjusted smoking rate than less acculturated men 98 (26.7% vs. 37.5%). 99 100 DISCUSSION 101 This review found a consistent positive association between acculturation and smoking among 102 Hispanic women but not men, indicating a differential association of acculturation and current 103 smoking status by gender. Specifically, nine of the eleven studies involving women reported a 104 significant positive association between acculturation and current smoking status. In these 105 studies, more acculturated women were more likely to be current smokers. In contrast, only one 106 of the eight studies involving men found a significant association between acculturation and 107 current smoking status and this relationship was negative; an increase in acculturation was 108 associated with a lower prevalence of current smoking. 109 The low smoking rates of women in Mexico may help explain the presence of an association 110 between acculturation and smoking among Hispanic women in the U.S. The second and third 111 editions of Mexico’s National Survey of Addictions (ENA-93 and ENA-98) found female 112 smoking rates of 16.3% and 18.4% in Mexico, respectively.32,33 These are lower than the rates 113 reported among non-Hispanic white women and more acculturated Hispanic women found in 114 this review. Authors from two studies in this review suggest that the association between 115 acculturation and female Hispanics may simply reflect the current social norms for smoking in Bethel-smoking_v8.doc 9 116 the United States.15,16 As Hispanic women acculturate, their cigarette smoking rates increase 117 because their behavior becomes more strongly influenced by the norms and practices of the 118 dominant group; therefore, their smoking rates will become closer to those of the U.S. non- 119 Hispanic white population. 120 The specific reason why Hispanic women are more susceptible than Hispanic men is unknown; 121 however, researchers have provided sociological and psychological theories to help explain this 122 observation. Cigarette smoking may be a way for a Hispanic woman to establish her 123 independence in American society. Cigarette smoking may also symbolize the acquisition of 124 greater equality of status in society associated with changing gender roles and employment 125 opportunities. Also, the abandonment of Hispanic social pressures, which traditionally helped 126 prevent cigarette smoking among women but not men may also contribute to the observed 127 differences by gender.35,36 Finally, differential exposure to acculturative stress by gender may 128 also explain the association between acculturation and smoking among women but not among 129 men.37 130 The high smoking rates of men in Mexico may explain the absence of an association between 131 acculturation and smoking among Hispanic men in the U.S. The second and third editions of 132 Mexico’s National Survey of Addictions (ENA-93 and ENA-98) found male smoking rates of 133 42.9% and 51.2%, respectively. These rates are much higher than the overall smoking 134 prevalence of non-Hispanic white men in the U.S. (24.0%)2 but similar to rates reported in a few 135 of the studies under review. According to the idea that immigrants’ smoking rates will equal 136 those of the dominant group, male Hispanic smoking rates should decrease from their higher 137 levels in Mexico to the level of non-Hispanic whites in the U.S. Only one study showed this Bethel-smoking_v8.doc 10 138 negative relationship and two studies showed a negative relationship between acculturation and 139 smoking which was not statistically significant.11,18 140 Results from this review were evident across acculturation measures used. The positive 141 relationship between acculturation and smoking among women was present in studies that used 142 formal acculturation scales as well as in studies that used proxy measures. Six of the seven 143 studies that used formal acculturation scales and three of the four studies that utilized country of 144 birth and/or language spoken as proxies reported this trend. The seven studies that did not find a 145 significant association between acculturation and current smoking status among men utilized 146 formal acculturation scales as well as country of birth and/or language spoken as proxy 147 measures. The results found were also consistent across studies that presented prevalence values 148 only, adjusted prevalence values (age- and/or education-adjusted), and multivariate logistic 149 regression results. Although only two studies used the same acculturation scale, systematic 150 differences between the scales would not explain the differential association between 151 acculturation and smoking by gender because the same study instrument was used on men and 152 women. Also, the use of the various scales in different populations in the western U.S. and 153 nationwide demonstrates that the observed association between acculturation and smoking was 154 externally valid. 155 The trends discovered in this review, however, cannot be generalized to the entire Hispanic 156 population throughout the U.S. All seven of the regional studies included Hispanics who were 157 predominantly or entirely Mexican-American. These studies were based in Western U.S. states 158 such as Colorado, California, Texas, New Mexico, and Arizona. Also, three of the four 159 nationwide studies used Mexican-American sub-samples for their analyses instead of the entire 160 Hispanic sample. Therefore, it may only be appropriate to generalize these results to Mexican- Bethel-smoking_v8.doc 11 161 Americans. The large sample sizes, sophisticated sample schemes of the nationwide studies such 162 as the HHANES and NHANES, and strong internal validity of the study populations allow the 163 results to be adequately generalized to the Mexican-American population. 164 Regardless of the acculturation measures used in these studies, a potential source of bias exists. 165 Seven studies in this review used formal scales to assess acculturation and six of these studies 166 used primarily language-based acculturation scales. The language-based scales (including the 167 Acculturation Rating Scale for Mexican Americans, ARSMA-I) measure acculturation linearly 168 with Mexican culture at one extreme and American culture at the other. Thus, acculturation is 169 defined as a linear movement in one direction of the continuum.19 This definition assumes that 170 strengthening of one ethnic tie requires weakening of the other. These measures do not account 171 for those biculturals who score high in the two cultures. Two-dimensional models should be 172 used which stress that acculturation is a process in which the relation to the culture of origin and 173 the new culture can be considered simultaneously. ARSMA-II was developed to address these 174 concerns, but was not used in any of the studies in the review.20 175 Four studies utilized proxy measures for acculturation such as nativity, length of U.S. residence, 176 language preference, and generation status.8,10,11,17 These studies make similar linear 177 assumptions as seen in the language-based acculturation scales. Many public health studies use 178 proxy measures to represent the complicated acculturation process. These measures are 179 particularly convenient because they are often found in secondary data sources such as Vital 180 Statistics records and national databases. However, these measures are limited in their ability to 181 adequately assess an individual’s level of acculturation, and these limitations have not been 182 sufficiently evaluated. Bethel-smoking_v8.doc 12 183 Another potential source of bias shared by all studies in the review was the self-reporting of 184 cigarette use. Cigarette use has been falsely reported and underreported among New Mexico 185 Hispanics and among a sub-sample of the Mexican-American population in HHANES.21,22 186 Thus, the smoking prevalence reported in these studies may be underestimates. An analysis of 187 Mexican-American smokers in HHANES indicated that at least 20.4% of men and 24.7% of 188 women who reported smoking less than 10 cigarettes per day may have underreported their 189 actual consumption. However, we are unable to confirm this underreporting, or to compare it to 190 inaccurate reporting among non-Hispanics. We do not believe that inaccuracies in reporting 191 smoking prevalence would invalidate the basic conclusions of this review. 192 The findings from this review suggest that some of the processes of acculturation are gender- 193 specific. Specifically, gender modified the effect of acculturation on smoking behavior among 194 Hispanics. Again, as Hispanic women acculturate, their cigarette smoking rates increase because 195 their behavior becomes more strongly influenced by the dominant group; therefore, their 196 smoking rates will become closer to those of the U.S. non-Hispanic white population. Smoking 197 cessation and prevention programs should be customized to address the needs of specific 198 Hispanic subpopulations. Female Hispanic immigrants are a group particularly susceptible to 199 smoking initiation upon arrival in the U.S. Public health interventions need to account for the 200 unique acculturation experience of Hispanics entering the U.S. Specifically, gender-specific and 201 immigrant-specific approaches are necessary to halt the increase in smoking among Hispanics 202 before it begins. Bethel-smoking_v8.doc 13 203 REFERENCES 204 1. Centers for Disease Control and Prevention. Annual smoking-attributable mortality, years 205 of potential life lost, and economic costs – United States, 1995-1999. MMWR Morb 206 Mortal Wkly Rep 2002;51(14):300-3. 207 208 209 210 211 212 213 214 215 216 2. Centers for Disease Control and Prevention. Cigarette smoking among adults – United States, 2001. MMWR Morb Mortal Wkly Rep 2003;52(40):953-956. 3. Padilla AM. Acculturation: Theory, Models, and Some New Findings. Boulder, Colo: Westview Press; 1980. 4. Burnam AM, Telles CA, Karno M, Hough RL. 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Am J Public 238 Health 1990;80 Suppl:47-53. 239 240 241 242 243 16. Marin G, Perez-Stable EJ, Marin BV. Cigarette smoking among San Francisco Hispanics: the role of acculturation and gender. Am J Public Health 1989;79(2):196-8. 17. Markides KS, Coreil J, Ray LA. Smoking among Mexican-Americans: a three generation study. Am J Public Health 1987;77(6):708-11. 18. Perez-Stable EJ, Ramirez A, Villareal R, Talavera GA, Trapido E, Suarez L, et al. 244 Cigarette smoking behavior among US Latino men and women from different countries 245 of origin. Am J Public Health 2001;91(9):1424-30. 246 247 19. Cuellar I, Harris JC, Jasso R. An acculturation scale for Mexican-American normal and clinical populations. Hisp J Behav Sci 1980;2(3):199-217. Bethel-smoking_v8.doc 15 248 20. Cuellar I, Arnold B, Maldonado R. Acculturation Rating Scale for Mexican-Americans- 249 II: A Revision of the Original ARSMA Scale. Hisp J Behav Sci 1995;17(3)275-304. 250 21. 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Richardson JL, Marks G, Solis JM, Collins LM, Birba L, Hisserich JC. Frequency and 265 adequacy of breast cancer screening among elderly Hispanic women. Prev Med 266 1987;16(6):761-74. 267 27. Ruiz MS, Marks G, Richardson JL. Language acculturation and screening practices of 268 elderly Hispanic women. The role of exposure to health-related information from the 269 media. J Aging Health 1992;4(2):268-81. Bethel-smoking_v8.doc 16 270 28. Balcazar H, Peterson G, Krull J. Acculturation and family cohesiveness in Mexican- 271 American pregnant women: social and health implications. Fam Community Health 272 1997;20:16-31. 273 274 275 276 277 278 279 280 281 282 283 284 285 29. Delgado JL, Johnson CL, Roy I, Trevino FM. Hispanic Health and Nutrition Examination Survey: methodological considerations. Am J Public Health 1990;80 Suppl:6-10. 30. Marin G, Sabogal F, Marin B, Otero-Sabogal R, Perez-Stable EJ. Development of a short acculturation scale for Hispanics. Hisp J Behav Sci 1997;9:183-205. 31. Markides KS, Levin JS, Ray LA. Determinants of physician utilization among MexicanAmericans. A three generation study. Med Care 1985;23(3):236-46. 32. Tapia-Conyer R, Kuri-Morales P, Hoy-Gutierrez MJ. An Epidemiologic Overview of Smoking in Mexico. Salud Publica Mex 2001;43(5): 1-6. 33. Secretaria de Salud, Direccion General de Epidemiologica. Encuesta Nacional de Adicciones 1998 (ENA-98). Mexico, D.F.: SSA, 1998. 34. Cuellar I, Harris LC, Jasso R. An acculturation scale for Mexican-American normal and clinical populations. Hispanic Journal of Behavioral Science 1980;2(3):199-217. 35. Marin G, Marin BV, Otero-Sabogal R, Sabogal F, Perez-Stable EJ. The role of 286 acculturation in the attitudes, norms, and expectancies of Hispanic smokers. J Cross- 287 Cultural Psychol 1989; 20:399-415. 288 36. Marin G, Marin BV, Otero-Sabogal R, Sabogal F, Perez-Stable EJ. Cultural differences 289 in attitudes towards smoking: developing messages using theory of reasoned action. J 290 Appl Soc Psychol 1990; 20:478-93. 291 292 37. Janes CR. Migration, changing gender roles and stress: the Samoan case. Med Anthropol 1990; 12:217-48. Bethel-smoking_v8.doc 17 Table 1. Review of studies on smoking and acculturation Year Site Study Population Sample Size 2000 Colorado Pregnant Women 331 1999 Los Angeles Women 46-92 573 1999 Arizona Women 18-65 76 1991 Nationwide Men & Women 20-74 3464 Haynes et al. 1990 Nationwide Men & Women 20-74 3464 Marin et al.15 1989 California Men & Women 15-64 1669 Markides et al.16 1987 Texas Men & Women 18-80 1125 1993 California Men & Women 18+ 3164 2001 Nationwide Men & Women 18+ 8882 1992 New Mexico Men & Women 18+ 1072 1999 Nationwide Men & Women 25-64 2791 Study Authors Acevedo7 11 Cantero et al. Coonrod et al. 12 13 Coreil et al. 14 Palinkas et al.8 17 Perez-Stable et al. 9 Samet et al. 10 Sundquist et al. Bethel-smoking_v8.doc 18 Table 2. Current smoking rates in Hispanics by study location and gender Current Smoking Rate Men Women Prevalence Ratioa Acevedo -- 13.0% -- Cantero et al. -- 16.4% -- Coonrod et al. -- 17.8% -- Marin et al. 32.4% 16.8% 1.93 Markides et al. 45.8% 22.9% 2.00 Palinkas et al. 24.5% 11.5% 2.13 Samet et al. 29.6% 26.1% 1.13 Coreil et al. 43.4% 24.8% 1.75 Haynes et al. 40.0% 25.0% 1.60 Perez-Stable et al. 25.0% 12.1% 2.07 Sundquist et al. 31.1% 15.7% 1.98 Study Authors Western States Nationwide a Men prevalence/women prevalence Bethel-smoking_v8.doc 19 Table 3. Association of acculturation and smoking and acculturation measures used Association of Acculturation and Smoking Study Authors Acevedo Cantero et al. Men --- Women Positive Positive Acculturation Measure(s) Language spoken 11-item acculturation scale18,2226 , years living in US Coonrod et al. -- Positive General Acculturation Index27, birthplace, years living in US Coreil et al. None Positive 8-item acculturation scale18 Haynes et al. None Positive 8-item acculturation scale28,32 Marin et al. Negative Positive 5-item acculturation scale29 Markides et al. None None Palinkas et al. Perez-Stable et al. None None Positive Positive Samet et al. None None Sundquist et al. None Positive Bethel-smoking_v8.doc Ethnicity of friends, language, and traditional values scales30 Language spoken 5-item acculturation scale29, birthplace Language spoken Birthplace and language spoken