Overview: Tobacco-Related
Disparities Among Hispanics/Latinos
Centers for Disease Control and Prevention
Office on Smoking and Health
2005 National Conference on Tobacco or Health
May 4, 2005
TM
Introduction
Overview: Tobacco-Related Disparities Among Hispanics/Latinos
Nisha Gupta, MPH
Office on Smoking and Health
2005 National Conference on Tobacco or Health
May 4, 2005
TM
Topics
 Program Development and Capacity Building
Debra Torres
 Smoking among Hispanics/Latinos
Ralph Caraballo
 Border Region Opportunities and OSH Initiatives
Nisha Gupta
 Hispanic/Latino Adult Tobacco Survey
Ralph Caraballo
Program Development
& Capacity Building
Debra S. Torres, MPH
Office on Smoking and Health
2005 National Conference on Tobacco or Health
May 4, 2005
TM
Why Focus on Hispanic/Latinos?
 Fastest growing sub-group of the U.S. population
 Younger than general population
Who are Hispanic/Latinos ?
 Heterogeneous
– Country of origin
– Geographic region
– Immigration status
– Language
– Acculturation levels
– Education
– Socio-economic status
Social Context
 Most likely to live in poverty
 Lower proportion of people
aged 25 > with at least a high
school diploma
 More likely to be unemployed
 Less likely to be covered by
health insurance
Social Context - 2
 Hispanic/Latinos similar mortality outcomes as
non-Hispanic Whites?
– Data aggregated for Hispanic/Latino’s as a whole
– Socio-demographic characteristics
– Some studies not conducted in Spanish
Program Planning,
Development & Implementation
 Consider challenges and opportunities
Challenges
 Competing priorities
social and health issues
 Targeting by tobacco
industry
– Advertising
– Sponsorship
– Philanthropy
Opportunities
 Family oriented
 Value traditions and
culture
 Strong social networks/
sense of community
 Commitment to social
justice issues
“Forty Years ago, Cesar Chavez led
the struggle for better working
conditions for Hispanic/Latino farm
workers in the United States. As a
leader, he made sure workers were
paid fair wages and were protected
from the dangerous chemicals in
the fields.”
Latino/a Research & Policy Center
Today Hispanic/Latinos still struggle with
exposure to deadly chemicals in the
workplace exposure to secondhand smoke.
Hispanic/Latino’s are the least protected
group by comprehensive smoke-free policies
in the workplace.
Program Planning Strategies
 Identify stakeholders
 Engage stakeholders
 Obtain skilled Hispanic/
Latino facilitator
Program Planning/Development Strategies
 Increase quantitative and qualitative data
 Tailor interventions
Program Strategies
 Develop and implement
– Community competent
– Comprehensive interventions
• Prevent initiation: youth and young adults
• Promote quitting among adults and youth
• Reduce exposure to secondhand smoke
Program Strategies - 2
 Monitor industry marketing tactics
 Link tobacco control with other health and
social issues
 EVALUATE, EVALUATE, EVALUATE
 Publish findings
On-Going Program Activities
 Cultivate partnerships
 Foster inclusivity
On-Going Program Activities - 2
 Build capacity
 Allocate resources
 Sustain funding
 Provide training and technical assistance
Health Communications
 Avoid direct translations
 Develop tailored messages
 Use local Hispanic/Latino media outlets
ie., Univision, radio, newspapers
 Place messages in mainstream media outlets
Take Home Message
 Get to know your community
 Engage community
 One size doesn’t fit all
 Context is key
Conclusion
“Envision a future where those responsible for
addressing tobacco prevention and cessation take
on a major role in ensuring culturally competent
services and participate in advocacy initiatives to
reduce tobacco related disparities among Hispanic
Latinos.”
Hispanic Latino Education Network of California
Program Development
& Capacity Building
Debra S. Torres, MPH
Office on Smoking and Health
2005 National Conference on Tobacco or Health
May 4, 2005
TM
Smoking among Hispanics/Latinos
Ralph Caraballo, PhD, MPH
Office on Smoking and Health
2005 National Conference on Tobacco or Health
May 4, 2005
TM
Topics to be Covered
 Hispanic/Latino Demographics in the U.S.
 Tobacco Industry Advertising for Latinos
 Smoking Prevalence and Trends
 Secondhand Smoke Exposure
 Smoking during pregnancy
U.S. Hispanic/Latino Demographics
Uniqueness: Specific Population Groups
 Important to understand the diversity and
uniqueness of specific populations
 What we think is one group may be several,
with varying customs and needs
Percent Distribution of Hispanics/
Latinos by Ancestry: 2004
8%
Mexican
South American
Central American
10%
Dominican
63%
4%
Cuban
Puerto Rican
3%
All Other Hispanic
7%
5%
Source: Hispanics: A People in Motion; The Pew Hispanic Center, January 2005
Hispanics/Latinos in U.S. by Ancestry: 2002
30
25.1
25
Millions
20
15
10
5.3
5
3.2
2.4
1.4
0
Mexico
Central and
South
America
Puerto Rico
Source: Current Population Survey, March 2002, PGP-5
Other
Hispanic
Cuba
Population Growth:
U.S. Population by Race/Ethnicity
12.6%
24.4%
2000
2050
69.4%
White
Hispanic
50.1%
Black
AAPI
AIAN
Source: U.S. Census Bureau, 2004, "U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin,"
www.census.gov/ipc/www/usinterimproj
Internet Release Date: March 18, 2004
Hispanic/Latino Population—United States
110
102.6
Population in millions
100
87.6
90
80
73.1
70
59.7
60
47.7
50
35.6
40
30
22.4
20
10
0
1990
2000
2010
2020
2030
2040
Source: U.S. Census Bureau, 2004, "U.S. Interim Projections by Hispanic Origin,"
www.census.gov/ipc/www/usinterimproj
Internet Release Date: March 18, 2004
2050
10 U.S. States Where 80% of Hispanics
Reside (Year 2000)
NY
NJ
NV
CA
IL
CO
AZ
NM
TX
FL
High Percent of Hispanics
Lower Percent of Hispanics
Census 2000: Top 10 States by Hispanic
Percent Change Since 1990
N. Carolina
394
Arkansas
337
Georgia
300
Tennessee
278
Nevada
217
S. Carolina
211
Alabama
208
Kentucky
Minnesota
Nebraska
173
166
155
Percent change
Language Use Among U.S. Hispanic/Latino
Adults, 2002
50
47.0
Spanish Dominant
Bilingual
English Dominant
Millions
40
30
28.0
25.0
20
10
0
Source: Pew Hispanic Center/Kaiser Family Foundation National Survey of Latinos, December 2002
Native/Foreign Born U.S. Hispanics/Latinos: 2004
Native Born
70
60
Percent
50
Foreign Born
55.4
44.6
40
30
20
10
0
Source: Pew Hispanic Center tabulations from the Annual Social and Economic Supplement, Current
Population Survey, March 2004
Legal/Undocumented Hispanics/Latinos:
Living in U.S.: 2004
Legal
50
Undocumented
40
Millions
31.6
30
20
10
8.4
0
Source: Pew Hispanic Center estimates based on March 2004 Current Population Survey (Passel 2005).
Includes an allowance for persons omitted from the CPS.
No Health Insurance by Race/Ethnicity and
Place of Birth (Native vs. Foreign), 2004
70
Native
Foreign
60
50.2
Percent
50
40
31.1
30
20.9
20
21.5
18.6
13.8
16.1
10.9
10
0
Hispanic
Black
Asian
White
Source: U.S. Census Bureau, Current Population Survey, 2004, Annual Social and Economic Supplements
Percent with Less Than 9th Grade Completed
by Hispanic/Latino Origin: 2002
35
32.1
(Population 25 years and over)
30
Percent
25
22.3
19.2
20
15.4
15
10
4.0
5
0
Mexican
Central and
South
American
Cuban
Source: Current Population Survey, March 2002, PGP-5
Puerto Rican Non-Hispanic
White
Smoking among Youth
Targeted Marketing and Promotion
 Magazines
 Point of purchase advertising
Current Smoking among Latino Adolescents
(12-17 years), by Gender, 1999-2001
20
Boy
Girl
18
16
14.3
Percent
14
12
11.4
10.0
10.6
11.2
10.4
10
9.9
9.3
8
6
4
2
0
Cuban
Mexican
Source: National Survey on Drug Use and Health, 1999-2001
Puerto
Rican
Central and
South American
Current Smoking among Youth 12-17 Years:
Mexico (urban), Mexico (rural), and
U.S. Mexican/Mexican-American
Urban
30
Rural
Mexican/Mexican Americans
Percent
20
15.4
11.3
11.4
10.6
11
10.1
10
6.1
4.8
1.0
0
Boy
Girl
Overall
Source: Encuesta Nacional de Adicciones, México, 2002, and National Survey on Drug Use and Health, 1999-2001
Current Smoking among Youth 12-17 Years:
Urban vs. Rural: United States, 2002
Urban
30
Rural
20.7
Percent
20
13.0
10
0
Overall
Source: Encuesta Nacional de Adicciones, México, 2002, and National Survey on Drug Use and Health, 1999-2001
Smoking among Adults
Smoking* Trends: Adults, 1983-2002
50
40
American Indian/Alaska Native
Percent
African American
30
20
White
Asian/Pacific Islander
Hispanic/Latino
HP 2010
Goal
(12%)
10
0
19831985
19871988
19901991
19921993
19941995
19971998
Years
* Smoking on 1 or more of the previous 30 days.
Source: National Health Interview Surveys, 1983-2002, selected years, aggregate data
19992000
20012002
Current Smoking: Hispanic/Latino Adults,
by Specific Population, 1999-2001
60
50
Percent
40
30.4
30
22.8
21.3
20
23.1
19.2
HP 2010
Goal
(12%)
10
0
Puerto Rican
Mexican
Central or
South American
Source: National Survey on Drug Use and Health, 1999-2001
Cuban
Overall
Current Smoking Among Adults, by
Specific Population Gender: 1999-2001
Men
50
Women
40
Percent
34.2
30
29.8
27.3
26.3
21.1
20
15.6
16.9
17.5
10
0
Puerto
Rican
Mexican
Source: National Survey on Drug Use and Health, 1999-2001
Central and
South
American
Cuban
Current Smoking among Adults:
Mexico (urban), Mexico (rural), and
U.S. Mexican/Mexican-American
Urban
60
50
Rural
Mexican/Mexican Americans
45.3
Percent
40
32.3
30
30.2
29.8
22.8
18.4
20
10
15.6
16.6
4.2
0
Men
Women
Overall
Source: Encuesta Nacional de Adicciones, México, 2002, and National Survey on Drug Use and Health, 2002
Adult Smoking Prevalence Among Hispanics, by
Gender And Survey Language, Oregon, 2000-01
n
Percent
95% C.I.
Men
English
Spanish
265
355
25
20
19.3 - 29.7
16.1 - 24.5
Women
English
Spanish
371
300
20
3
16.1 - 24.3
0.8 - 4.5
Projection*: Adult Smokers (in millions) by
Race/Ethnicity and Year
Population
Am. Indian
2000
<1.0
2025
<1.0
2050
1.0
Asian Am.
1.1
2.3
4.1
NH-Black
5.6
7.9
9.9
Hispanic
3.8
7.6
12.6
36.8
40.3
41.1
White
*Assumption: Same smoking rates of Year 2000 (NHIS) apply
Secondhand Smoke Exposure (SHS)
Secondhand Smoke Exposure (SHS)
SHS causes lung cancer and
heart disease morbidity and
mortality in adults, as well as
respiratory problems, SIDS,
low birth weight, and middle
ear infections in children
CAL EPA Report, 1997
Secondhand Smoke Risks
 Children at home
 Non-smoking spouses at home
 Non-smoking workers in workplaces
 Non-smoking patrons in restaurants,
bars, and gaming venues
Percentage of Nonsmokers Exposed to
Secondhand Smoke in the U.S., 1999-2000
 74% of African Americans
 52% of Whites
 47% of Mexican Americans / Mexicans
Source: National Health and Nutrition Examination Survey, 1999-2000
Percentage of Children (nonsmokers) Exposed to
Secondhand Smoke, by Age and Race/Ethnicity—
United States, 1999-2000
African American
100
Percentage
70
Mexican American
86.7
90
80
White
76.5
66.5
60
62.6
54.7
47.5
50
HP 2010 Goal
(45%)
40
30
20
10
0
3 to 4 years
Source: National Health and Nutrition Examination Survey, 1999-2000
5 to 11 years
Percentage of Nonsmokers Aged 12 – 19 Years
Exposed to Secondhand Smoke, by Race/Ethnicity—
United States, 1999-2000
African American
100
90
White
Mexican American
80.9
80
Percentage
70
65
60
50
40
30
20
10
0
Source: National Health and Nutrition Examination Survey, 1999-2000
50.9
HP 2010 Goal
(45%)
Percentage of Adult Nonsmokers Exposed to
Secondhand Smoke, by Race/Ethnicity and Age—
United States, 1999-2000
African American
100
White
Mexican American
90
80
Percentage
70
68.8
65.9
59.3
60
50
47.6
45.5
47.3
38.6
40
HP 2010 Goal
(45%)
39.5
29.7
30
20
10
0
20 - 34
35 - 64
Source: National Health and Nutrition Examination Survey, 1999-2000
65+ years
Percentage of Mexicans/Mexican Americans
(nonsmokers) Exposed to Secondhand Smoke, by
Age—United States, 1999-2000
60
54.7
47.5
50
50.9
45.5
38.6
40
Percent
HP 2010 Goal
(45%)
29.7
30
20
10
0
3–4
5 – 11
12 – 19
20 – 34
AGE
Source: National Survey on Drug Use and Health, 1999-2001
35 – 64
65+
Smoking During Pregnancy
Percent of Mothers Who Smoked During
Pregnancy by Race/Ethnicity of Mother—
United States, 1999
25
20.2
20
Percent
15.9
15
14.7
10.5
10
5
9.4
4.5
3.3
3.3
2.6
1.4
0.5
0
American White Hawaiian Puerto
Indian/
Rican
Alaska Native
Black Japanese Cuban Filipino Mexican Central/ Chinese
South
American
Source: National Vital Statistics Report, Vol. 49, No. 7, August 28, 2001
Note: California and South Dakota did not report in 1999
Smoking among Hispanics/Latinos
Ralph Caraballo, PhD, MPH
Office on Smoking and Health
2005 National Conference on Tobacco or Health
May 4, 2005
TM
Border Region Opportunities
and OSH Initiatives
Nisha Gupta, MPH
Office on Smoking and Health
2005 National Conference on Tobacco or Health
May 4, 2005
TM
Office on Smoking and Health (OSH)
Initiatives
 Hispanic/Latino Adult Tobacco Survey (ATS)
 Southwest States Initiative (SWSI)
 Environmental Scan
 Promotoras Project
 Binational Border Health Week, 2005
 Hispanic/Latino Community Outreach Project
Strategic Approaches
 Community Competency approach: history, culture,
context, geographic, heterogeneity, etc.
 Address tobacco related disparities in Hispanic/
Latino specific populations
 Link tobacco control to other health, social and
environmental issues
 Extrapolate and plan for future tobacco burden
U.S. Mexico Border Region
 2,000 miles – 62.5 miles north/south
 12 million inhabitants (double by 2025)
 25 Native American tribes in Border Region
Border Region Includes…
 Two nations
 44 counties
 80 municipalities
 14 pairs of sister cities
Gateway for Two Countries
 Every day 800,000 people
arrive in U.S.
 Over 300 million two-way
border crossings 2001
 43 points of entry
Southwest States Profile
 Proportion of smoking, lack of physical activity, and
obesity among Hispanics/Latinos in 4 border states
much greater than the US Hispanic/Latino population
Southwest States Profile
 Avg. yearly income $14,560
 3 of 10 poorest counties in U.S.
 Almost ½ of the counties economically distressed
 1,200 rural colonias with over 432,000 inhabitants—
TX & NM
 Unemployment 250-300 percent higher
Southwest States Profile
If the border region were a
state, it would rank…
 Last in per capita income
 First in numbers of school
children living in poverty
 First in numbers of
children uninsured
Southwest States Profile
 Last in access to health
care
 Second in death rates
hepatitis
 Third in diabetes deaths
 High alcohol consumption
Alcohol Use Among Hispanic/Latinos
 U.S. born are 3 times more likely to
drink and drive than those born in
other countries but living in the U.S
 Abstention reported greater among
women immigrants to USA*
 Mexican-Americans have second highest alcohol-related
fatality rates
 Level of alcohol use strongly associated with illicit drug
use (2003) and tobacco use
Source: NSDUH, 2003
Gilbert, J. Alcohol consumption patterns in immigrant and later generation Mexican American women. Hispanic
Journal of Behavioral Sciences 9 (3): 299-313, 1987
Border Region Assets/Opportunities
 Culturally rich region
 Strong sense of community
 Grassroots self-help initiatives
 Promotora model
 Ranks better on some health-related behaviors and
outcomes than rest of U.S.
 Protective effect of cultural preservation/low
acculturation
 Commitment and expertise of state and local health
depts.
Opportunities/Objectives for OSH
 Address disparities in the border region
 Build capacity
 Collaboration and linkage with other health
salient health issues in border region
 Compatibility with STEPS awards
 Accelerate inclusion of tobacco in BHC
(Border Health Commission) 2010 HP Objectives
Border Region Opportunities
and OSH Initiatives
Nisha Gupta, MPH
Office on Smoking and Health
2005 National Conference on Tobacco or Health
May 4, 2005
TM
Hispanic Latino
Adult Tobacco Survey
Ralph Caraballo, PhD, MPH
Office on Smoking and Health
2005 National Conference on Tobacco or Health
May 4, 2005
TM
Topics
 Background of Hispanic/Latino
Adult Tobacco Survey (ATS)
 Development Hispanic/Latino ATS
 Latino ATS Cognitive Testing
 Conduct survey with Latino ATS in 2006
 End Products as a result of Latino ATS
Latino ATS: What Is It?
 A questionnaire that can be used for surveillance
and evaluation purposes
 Used state-based ATS questionnaire as a template
Latino ATS Questionnaire Sections
CORE
 Cigarette Smoking
 Smoking Cessation
 Secondhand Smoke Exposure
 Risk Perception and Social Influences
 Demographics
ATS Questionnaire Sections (cont.)
 Other questions can be added for specific purposes
– Tobacco Use (Other tobacco products)
– Policy Issues
– Parental Involvement
– Media Exposure
– Additional Demographic Items
– Other selected topics
Latino ATS: How It’s Used?
 Can provide surveillance and evaluation data at
state, regional and community (local) level
 Can direct culturally appropriate program planning,
evaluation and policy development
 May serve to develop culturally appropriate
prevention programs
Modifications to State ATS
 Expert Panel identified several tobacco-related
needs for Latinos
 Expert input on modifications to ATS
 Suggested changes implemented
 The final survey included 58 items:
– 35 original items
– 4 original items modified
– 19 new items added to questionnaire
Key Added Questions to Latino ATS
Cessation Section
– In the past 12 months, have you seen a
• medicine Man (curandero)
• santero
• spiritist (Espiritista)
• herbalist (yerbero)
• religious leaders (priest, pastor, rabbi)
• other non-health professionals to help you quit
smoking?
Key Added Questions to Latino ATS
Demographics
– With which group do you identify yourself (please select
only one)?
1. Mexican, Mexican American, Chicano
2. Puerto Rican
3. Cuban
4. Other Caribbean
5. Central American
6. South American
7. Spanish, from Spain
8. Mixed Latino
9. Other (specify): __________
Key Added Questions to Latino ATS
Demographics
– What is your country of birth?
1. Argentina
2. Bolivia
3. Brazil
4. Chile
5. Colombia
6. Costa Rica
7. Cuba
8. Dominican Republic
9. Ecuador
10. El Salvador
11. Guatemala
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
Honduras
Mexico
Nicaragua
Panama
Paraguay
Peru
Puerto Rico
Spain
Uruguay
Venezuela
United States
Other (specify): ____________
Key Added Questions to Latino ATS
Demographics
– How old were you when you first came to live in the
United States?
AGE: ________
Key Added Questions to Latino ATS
Demographics
– In general, what language(s) do you speak?
1.
2.
3.
4.
5.
7.
9.
Only English
English better than Spanish
Both Equally
Spanish better than English
Only Spanish
Don’t Know/Not sure
Refused
Cognitive Testing of Hispanic/Latino ATS
 Round 1 (end of 2004 and beginning of 2005)
– Chicago, Illinois
– El Paso, Texas
 Round 2 (March and April 2005)
– New York city, New York
– Miami, Florida
 A total of 80 interviews
Cognitive Testing of Hispanic/Latino ATS
Round 1: Chicago, Illinois and El Paso, Texas
– 40 completed interviews
• 28 in Chicago
• 12 in El Paso
– 35 interviews in Spanish and 5 in English
•
•
•
•
•
14 Mexicans
5 Guatemalan
4 Puerto Ricans
4 Colombians
3 Salvadorians
3 Honduras
2 Dominican Republic
2 Ecuador
2 Peru
1 Cuban
Cognitive Testing of Hispanic/Latino ATS
Round 1: Chicago, Illinois and El Paso, Texas
– Breakdown by Gender:
• Males:
14
• Females: 26
Cognitive Testing of Hispanic/Latino ATS
Round 1: Chicago, Illinois and El Paso, Texas
– Breakdown by Education:
• 0 – 8th grade:
7
• 9 – 11th grade: 4
• HS (or GED):
10
• 13+:
19
Cognitive Testing of Hispanic/Latino ATS
Round 1: Chicago, Illinois and El Paso, Texas
– Breakdown by Income:
• < $10,000:
• $10,000 - $19,999:
• $20,000 - $29,999:
4
13
4
• $30,000 - $39,999:
• ≥ $40,000:
7
12
Cognitive Testing of Hispanic/Latino ATS
Round 1: Chicago, Illinois and El Paso, Texas
– Spoken Language:
• Spanish only: 23
• English only:
4
• Both:
13
Cognitive Testing of Hispanic/Latino ATS
Round 1: Chicago, Illinois and El Paso, Texas
– Cigarette Smoker?:
• Yes: 16
• No: 24
Findings From the Cognitive Interviews
 Terminology
 Secondhand Smoke Exposure
 Policy Issues
 Demographic Items
Findings From the Cognitive Interviews
Terminology
 Would you say that breathing smoke from other
people’s cigarettes causes sudden infant death?
– The word “crib death” was better understood by
participants compared to the word “sudden infant
death syndrome”
Findings From the Cognitive Interviews
Secondhand Smoke Exposure
 How concerned are you about the health impact of
breathing smoke from other people’s cigarettes?
– Not worried answers mean different things. Some are
not worried because never exposed; others because
smokers themselves; others don’t think it’s so bad.
Findings From the Cognitive Interviews
Policy Issues
 When a smoking policy is already in place there is
no meaning for a “stronger workplace policy.”
Most participants support strong enforcement.
Findings From the Cognitive Interviews
Demographic Items
 Which one or more of the following would you say is
your race?
– Need to include Hispanic/Latino as a category as well
Next Steps
 Finalize cognitive testing (2005)
– New York city, New York
– Miami, Florida
 Finalize Spanish and English questionnaires (2005)
 Develop a Latino ATS Instructional Manual (2005)
 Make Latino ATS questionnaire and manual available
(2006)
 Conduct Latino ATS surveys in 3 locations (2006)
– El Paso, TX (face-to-face)
– New York city, NY (telephone)
– Miami, FL (telephone)
Overview: Tobacco-Related
Disparities Among Hispanics/Latinos
Any questions?
TM
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