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
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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
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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