Acculturation-related predictors of very light smoking among Latinos in California and nationwide

Smoking-Cessation Assistance Among Older Adults by Ethnicity/Language Preference

INTRODUCTION

Although smoking prevalence is lower among Hispanic adults than among non-Hispanic White adults, smoking remains a leading cause of preventable death among older Hispanics. This study examines the differences in tobacco assessment and smoking-cessation assistance among older patients seen in community health centers by ethnicity and language preference.

METHODS

Electronic health record data were extracted from the Accelerating Data Value Across a National Community Health Center Network of community health centers from patients aged 55‒80 years with ≥1 primary care visit between January 1, 2017 and December 31, 2018. Binary outcomes included tobacco use assessment and, among those with ≥1 status indicating current smoking, having a smoking-cessation medication ordered. The independent variable combined ethnicity and language preference, categorized as non-Hispanic White (reference), Spanish-preferring Hispanic, and English-preferring Hispanic. Multivariable generalized estimating equation logistic regressions, clustering by primary care clinic using an exchangeable working correlation structure, modeled the odds of tobacco use assessment and cessation medication orders by ethnicity/preferred language, adjusting for patient covariates, health system, and clinic location. Analyses were conducted in 2021.

RESULTS

The study included 116,328 patients. Spanish-preferring Hispanic patients had significantly lower odds of having tobacco use assessed than non-Hispanic White patients (AOR=0.89, 95% CI=0.82, 0.95). Both Spanish- and English-preferring Hispanic patients had lower odds of having a smoking-cessation medication ordered (AOR=0.53, 95% CI=0.47, 0.60; AOR=0.77, 95% CI=0.67, 0.89, respectively) than non-Hispanic White patients.

CONCLUSIONS

Significant disparities were found in tobacco assessment and cessation assistance by ethnicity and language preference among older adults seen in safety-net clinics. Future research is needed to understand the etiology of these smoking-related disparities.

Factors Associated With Receipt of Smoking Cessation Advice and Assistance by Health Professionals Among Latino and Non-Latino White Smokers With Medicaid Insurance in California

IMPORTANCE

Nationally, Latino smokers are less likely than non-Latino White smokers to receive advice and assistance from health professionals to quit smoking. California's Medicaid expansion included the Patient Protection and Affordable Care Act's comprehensive tobacco cessation benefits; however, it is unknown whether expanded coverage helped resolve this disparity.

OBJECTIVE

To examine the association between race and ethnicity (Latino and non-Latino White) and health professional cessation advice and assistance among smokers with Medi-Cal insurance in the post-Affordable Care Act period.

DESIGN, SETTING, AND PARTICIPANTS

This repeated cross-sectional study was conducted with the 2014 and 2016-2018 California Health Interview Survey. A total of 1861 Latino and non-Latino White current smokers aged 18 to 64 years who had Medi-Cal insurance and consulted a health professional in the past 12 months were included. Data were analyzed between December 1, 2019, and April 30, 2021.

EXPOSURE

Race and ethnicity classified as Latino or non-Latino White.

MAIN OUTCOMES AND MEASURES

The outcomes were receipt of health professional advice to quit smoking or assistance to quit in the past 12 months. Logistic regression was used to examine the association between race and ethnicity and each outcome, adjusted for sociodemographic factors, smoking behavior, health care factors, and acculturation measures. All estimates were weighted to adjust for the complex survey design.

RESULTS

Among 1861 participants, 44.8% were Latino, 53.8% were aged 40 years or older (mean [SE], 39.7 [0.79] years), 54.1% were male, and 59.9% had less than a high school education. Latino smokers were less likely than non-Latino White smokers to receive health professional advice (38.3% Latino smokers vs 55.3% non-Latino White smokers) or assistance (21.8% Latino smokers vs 35.7% non-Latino White smokers). In the unadjusted model, compared with non-Latino White smokers, Latino smokers were less likely to receive advice (odds ratio [OR], 0.50; 95% CI, 0.29-0.86) and also less likely to receive assistance (OR, 0.50; 95% CI, 0.25-1.00). However, in the adjusted model, race was no longer significant. Smokers with more office visits (adjusted OR, 2.44; 95% CI, 1.61-3.70) and those with at least 1 chronic disease (adjusted OR, 1.99; 95% CI, 1.15-3.43) were more likely to receive advice from a health professional. Additionally, daily smokers compared with nondaily smokers (adjusted OR, 2.29; 95% CI, 1.03-5.13) were more likely to receive assistance.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, more office visits, having a chronic disease, and daily smoking were associated with an increased likelihood of receiving smoking cessation advice or assistance. Use of strategies to engage tobacco users outside of the clinic, such as proactive outreach and community-based engagement, may help address this disparity.

Genome-Wide Association Study of Heavy Smoking and Daily/Nondaily Smoking in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

Introduction

Genetic variants associated with nicotine dependence have previously been identified, primarily in European-ancestry populations. No genome-wide association studies (GWAS) have been reported for smoking behaviors in Hispanics/Latinos in the United States and Latin America, who are of mixed ancestry with European, African, and American Indigenous components.

Methods

We examined genetic associations with smoking behaviors in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) (N = 12 741 with smoking data, 5119 ever-smokers), using ~2.3 million genotyped variants imputed to the 1000 Genomes Project phase 3. Mixed logistic regression models accounted for population structure, sampling, relatedness, sex, and age.

Results

The known region of CHRNA5, which encodes the α5 cholinergic nicotinic receptor subunit, was associated with heavy smoking at genome-wide significance (p ≤ 5 × 10-8) in a comparison of 1929 ever-smokers reporting cigarettes per day (CPD) > 10 versus 3156 reporting CPD ≤ 10. The functional variant rs16969968 in CHRNA5 had a p value of 2.20 × 10-7 and odds ratio (OR) of 1.32 for the minor allele (A); its minor allele frequency was 0.22 overall and similar across Hispanic/Latino background groups (Central American = 0.17; South American = 0.19; Mexican = 0.18; Puerto Rican = 0.22; Cuban = 0.29; Dominican = 0.19). CHRNA4 on chromosome 20 attained p < 10-4, supporting prior findings in non-Hispanics. For nondaily smoking, which is prevalent in Hispanic/Latino smokers, compared to daily smoking, loci on chromosomes 2 and 4 achieved genome-wide significance; replication attempts were limited by small Hispanic/Latino sample sizes.

Conclusions

Associations of nicotinic receptor gene variants with smoking, first reported in non-Hispanic European-ancestry populations, generalized to Hispanics/Latinos despite different patterns of smoking behavior.

Implications

We conducted the first large-scale genome-wide association study (GWAS) of smoking behavior in a US Hispanic/Latino cohort, and the first GWAS of daily/nondaily smoking in any population. Results show that the region of the nicotinic receptor subunit gene CHRNA5, which in non-Hispanic European-ancestry smokers has been associated with heavy smoking as well as cessation and treatment efficacy, is also significantly associated with heavy smoking in this Hispanic/Latino cohort. The results are an important addition to understanding the impact of genetic variants in understudied Hispanic/Latino smokers.

Disparities in knowledge and use of tobacco treatment among smokers in California following healthcare reform

The Affordable Care Act (ACA) promised to narrow smoking disparities by expanding access to healthcare and mandating comprehensive coverage for tobacco treatment starting in 2014. We examined whether two years after ACA implementation disparities in receiving clinician advice to quit and smokers' knowledge and use of treatment resources remained. We conducted telephone interviews in 2016 with a stratified random sample of self-reported smokers newly enrolled in the Kaiser Permanente Northern California's (KPNC) integrated healthcare delivery system in 2014 (N = 491; 50% female; 53% non-white; 6% Spanish language). We used Poisson regression with robust standard errors to test whether sociodemographics, insurance type, comorbidities, smoking status in 2016 (former, light/nondaily [<5 cigarettes per day], daily), and preferred language (English or Spanish) were associated with receiving clinician advice to quit and knowledge and use of tobacco treatment. We included an interaction between smoking status and language to test whether the relation between smoking status and key outcomes varied with preferred language. Overall, 80% of respondents received clinician advice to quit, 84% knew that KPNC offers cessation counseling, 54% knew that cessation pharmacotherapy is free, 54% used pharmacotherapy, and 6% used counseling. In multivariate models, Spanish-speaking light/nondaily smokers had significantly lower rates of all outcomes, while there was no association with other demographic and clinical characteristics. Following ACA implementation, most smokers newly enrolled in KPNC received clinician advice to quit and over half used pharmacotherapy, yet counseling utilization was low. Spanish-language outreach efforts and treatment services are recommended, particularly for adults who are light/nondaily smokers.

Revisiting the Relationship Between Acculturation and Smoking Cessation Among Mexican Americans

BACKGROUND

A well-established gender-differentiated association between acculturation and current smoking exists among Latino adults. There are far fewer studies on the potential influence of acculturation on smoking cessation, and extant findings are mixed.

PURPOSE

Using a multidimensional measure of acculturation, the current study examined the independent and interactive associations of gender and acculturation with smoking cessation among Mexican American smokers engaged in a quit attempt.

METHODS

Using a latent variable modeling approach to repeated measures analysis, the independent and interaction effects of acculturation in two cultural directions (American and Mexican) were examined for their prospective associations with smoking abstinence. Interactions of acculturation domains with gender were also examined. Acculturation was assessed at baseline and abstinence status was assessed at 3 and 26 weeks post-quit.

RESULTS

The interaction of American and Mexican cultural identity was significantly associated with smoking abstinence, such that greater American cultural identity was positively associated with abstinence only among those with high Mexican cultural identity. The interaction of English proficiency with gender was significant such that English proficiency was positively associated with abstinence among men but not women.

CONCLUSIONS

Findings in the cultural identity domain are consistent with a "benefits of biculturalism" perspective, and may be particularly relevant to the adoption of an American cultural orientation among persons with an already-strong heritage-culture orientation. Findings also replicate a gender-differentiated association between acculturation and cessation. Implications for treatment development and future research are discussed.

Factors associated with changing cigarette consumption patterns among low-intensity smokers: Longitudinal findings across four waves (2008-2012) of ITC Mexico Survey

Background

Light and intermittent smoking has become increasingly prevalent as smokers shift to lower consumption in response to tobacco control policies. We examined changes in cigarette consumption patterns over a four-year period and determined which factors were associated with smoking transitions.

Methods

We used data from a cohort of smokers from the 2008–2012 ITC Mexico Survey administrations to investigate transitions from non-daily (ND; n = 669), daily light (DL; ≤5 cigarettes per day (cpd); n = 643), and daily heavy (DH; >5 cpd; n = 761) smoking patterns. To identify which factors (i.e., sociodemographic measures, perceived addiction, quit behavior, social norms) were associated with smoking transitions, we stratified on smoking status at time t (ND, DL, DH) and used multinomial (ND, DL) and binomial (DH) logistic regression to examine transitions (quitting/reducing or increasing versus same level for ND and DL, quitting/reducing versus same level for DH).

Results

ND smokers were more likely to quit at follow-up than DL or DH smokers. DH smokers who reduced their consumption to ND were more likely to quit eventually compared to those who continued as DH. Smokers who perceived themselves as addicted had lower odds of quitting/reducing smoking consumption at follow-up compared to smokers who did not, regardless of smoking status at the prior survey. Quit attempts and quit intentions were also associated with quitting/reducing consumption.

Conclusions

Reducing consumption may eventually lead to cessation, even for heavier smokers. The findings that perceived addiction and quit behavior were important predictors of changing consumption for all groups may offer insights into potential interventions.

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Smoking transitions were evaluated in a cohort of Mexican smokers.

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The cohort consisted mostly of understudied light and intermittent smokers (LITS).

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Reductions in smoking intensity were found to facilitate smoking cessation.

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Greater perceived addiction inhibited cessation for smokers at all levels of intensity.

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LITS patterns warrant attention as number of low-intensity smokers worldwide grows.

Daily and Nondaily Smoking Varies by Acculturation among English-Speaking, US Latino Men and Women

Background

Higher smoking prevalence and quantity (cigarettes per day) has been linked to acculturation in the United States among Latinas, but not Latino men. Our study examines variation between a different and increasingly important target behavior, smoking level (nondaily vs daily) and acculturation by sex.

Methods

An online English-language survey was administered to 786 Latino smokers during July through August 2012. The Brief Acculturation Rating Scale for Mexican Americans-II (ARSMA-II) and other acculturation markers were used. Multinomial logistic regression models were implemented to assess the association between smoking levels (nondaily, light daily, and moderate/heavy daily) with acculturation markers.

Results

Greater ARMSA-II scores (relative risk ratio, RRR=.81, 95% CI: .72-.91) and being born inside the United States (RRR=.42, 95% CI: .24-.74) were associated with lower relative risk of nondaily smoking. Greater Latino orientation (RRR=1.29, 95% CI: 1.11-1.48) and preference for Spanish language (RRR=1.06, 95% CI: 1.02-1.10) and media (RRR=1.12, 95% CI: 1.05-1.20) were associated with higher relative risk of nondaily smoking. The relationship between acculturation and smoking level did not differ by sex.

Conclusion

This study found that among both male and female, English-speaking Latino smokers, nondaily smoking was associated with lower acculturation, while daily smoking was linked with higher acculturation.

Cultural values associated with substance use among Hispanic emerging adults in Southern California

INTRODUCTION

Hispanic emerging adults are a priority population for substance use prevention, yet few studies have examined whether traditional Hispanic cultural values serve as risk or protective factors for substance use among emerging adults. This study examined the relationship between familism, respeto, fatalism, and substance use among Hispanic emerging adults.

METHODS

Participants (ages 18 to 25) completed surveys indicating identification with familism, respeto, and fatalism, past month use of tobacco, marijuana, hard drugs and binge drinking. Separate logistic regression models examined the association between cultural values and each substance use outcome, controlling for acculturation, age and gender.

RESULTS

Among participants (n=1445, mean age=23, 60% female), 21% reported past month cigarette use, 18% reported past month alternative tobacco product (ATP) use, 25% reported past month marijuana use, 44% reported past month binge drinking, and 7% reported past month hard drug use. Higher fatalism scores were associated with increased ATP use. Higher familism scores were associated with binge drinking, while higher respeto scores were associated with decreased binge drinking, marijuana, and hard drug use.

CONCLUSION

These findings suggest that substance use prevention and intervention programs should emphasize how substance use interferes with caring and honoring parents (respeto) and family cohesion and functioning (familism). Programs that highlight these cultural values and beliefs may be beneficial for Hispanic emerging adults and members of other collectivistic cultures.

The Use of E-Cigarettes Among U.S. Immigrants: The 2014 National Health Interview Survey

OBJECTIVE

Although e-cigarette popularity has increased substantially in recent years in the United States, it is unclear whether e-cigarette use has extended to immigrants in the United States. We characterized differences in ever and current use of e-cigarettes among non-U.S. citizens, naturalized U.S. citizens, and U.S. natives.

METHODS

We used cross-sectional data from the 2014 National Health Interview Survey to measure the prevalence of e-cigarette ever and current use by immigration status, characterized as U.S. native, naturalized U.S. citizen, and non-U.S. citizen. We used multivariate logistic regression to examine the association between e-cigarette use and immigration status adjusting for demographic characteristics, socioeconomic status, and history of tobacco use. We also stratified the use of e-cigarettes by cigarette smoking status and analyzed the impact of length of residency and country of origin on e-cigarette use among immigrants.

RESULTS

Naturalized U.S. citizens and non-U.S. citizens had a similar prevalence of e-cigarette use, which was significantly lower than the prevalence among U.S. natives. After adjusting for covariates, naturalized U.S. citizens had 38% lower odds and non-U.S. citizens had 54% lower odds of ever using e-cigarettes than U.S. natives. Non-U.S. citizens were less likely than U.S. natives to currently use e-cigarettes. Among both current smokers and nonsmokers of tobacco cigarettes, non-U.S. citizens were less likely than U.S. natives to indicate current e-cigarette use. U.S. immigrants with >5 years residency were more likely than U.S. immigrants with <5 years residency to try e-cigarettes.

CONCLUSION

Although non-U.S. citizens are less likely than U.S. natives to currently use e-cigarettes, e-cigarette use may increase with length of residency in the United States.

Changes in Smoking Intensity Over Time by Birth Cohort and by Latino National Background, 1997-2014

INTRODUCTION

The purpose of the study was to describe changes in smoking intensity among US Latinos and non-Latinos from 1997 to 2014.

METHODS

National Health Interview Survey data between 1997 and 2014 were used to determine the number of cigarettes smoked per day (CPD) among Latino and non-Latino adults who had smoked at least 100 cigarettes in their lifetime and were currently smoking every day or some days (ie, current smokers).

RESULTS

CPD declined steadily throughout the observation period and were consistently lower for Latino than for non-Latino smokers. However, decreases were not equal across birth cohorts, genders, or among Latino national background groups. CPD declined most among Mexican men and least among younger generations, Cuban women, and acculturated Latina women. Additionally, declines in smoking intensity seemed to slow over time among low CPD consumers.

CONCLUSIONS

Although smoking intensity has decreased substantially since the late 1990s, CPD data suggest that declines are slowing among younger generations and certain Latina women. Effective tobacco control strategies should be developed to discourage even very light and nondaily smoking.

IMPLICATIONS

Few studies have been conducted on how smoking intensity has changed since the late 1990s. Between 2004 and 2011, when the decline in smoking prevalence slowed, it is unknown how smoking intensity (ie, CPD) changed by age. Additionally, no research has assessed differences and changes in smoking intensity over time among Latinos. From this study we learned that smoking intensity declined significantly since the late 1990s, but this decline slowed among younger generations of smokers and certain Latina women. Findings suggest that future patterns of smoking intensity may only marginally decline in the near future.