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. Author manuscript; available in PMC: 2025 Oct 1.
Published in final edited form as: J Ethn Subst Abuse. 2023 Jan 25;23(4):1016–1038. doi: 10.1080/15332640.2023.2167757

Early Trajectories of Cigarette and ENDS Use among Young Adult Recent Latino immigrants to U.S.

Eduardo Romano a, Mariana Sanchez b
PMCID: PMC10366335  NIHMSID: NIHMS1871935  PMID: 36695045

Introduction

In the United States (U.S.), tobacco control policies have been successful in reducing overall smoking rates from those prevailing in 1964 (HHS, 2014). Yet in 2018, an estimated 34.2 million U.S. adults (13.7%) used cigarettes (Creamer et al., 2019) and in 2014, cigarette smoking accounted for more than 480,000 deaths (HHS, 2014). This overall progress does not clearly reveal differences across and within racial-ethnic groups. In 2019, smoking prevalence was higher among non-Latino Whites (15.5%) and non-Latino African Americans (14.9%) than among Latinos (8.8%) (Cornelius, Wang, Jamal, Loretan, & Neff, 2020). Despite their relative lower rates, smoking remains a substantial health risk for Latinos, as it is a major contributor to premature death and disability (Zvolensky et al., 2019), and it has been strongly associated with diabetes, hypertension and cardiovascular disease (Daviglus, Pirzada, & Talavera, 2014; Moore Simas et al., 2014).

There is ample consensus that overall, Latinos who were born abroad are less likely to be current cigarette smokers than their U.S.-born counterparts. Smoking rates among foreign-born Latinos have been found to increase as their time in the U.S. increases (Abraído-Lanza, Chao, & Flórez, 2005; Finch & Vega, 2003; Kaplan et al., 2014; Ornelas, Eng, & Perreira, 2011; Trinidad, Pérez-Stable, White, Emery, & Messer, 2011). Smoking among foreign-born Latinos has also been associated with high levels of acculturation, low education level, age (e.g., those aged 60 or over being less likely to be current smokers than their younger counterparts), and sex (typically men smoking more than women)(Kaplan et al., 2014; Pérez-Stable et al., 2001; Rodriquez, Fernández, Livaudais-Toman, & Perez-Stable, 2019).

For foreign-born Latino/a immigrants, it is likely their experiences with substance use in their country of origin influence their use after immigration. While evidence of such pre- to post-immigration influence has been shown associated with alcohol use (Sanchez et al., 2014), our existing knowledge on the influence that pre-immigration tobacco experiences affect tobacco use in the U.S. is limited (Koya & Egede, 2007; Pampel, Khlat, Bricard, & Legleye, 2020).

Since 2020, sales of electronic nicotine delivery system (ENDS) in the U.S. have grown substantially (Azagba & Shan, 2021; King, Patel, Nguyen, & Dube, 2015; Villarroel, Cha, & Vahratian, 2020). However, while there is evidence of an increasing prevalence of e-cigarette use among non-Hispanic white younger adults (Villarroel et al., 2020), there is a dearth of knowledge about the use of ENDS among immigrant populations (Azagba & Shan, 2021; Wang, Wilson, Larson, & Chen, 2016). There is consensus among researchers that rates of e-cigarette use are lower among immigrants than among U.S. born individuals (Acevedo-Garcia, Pan, Jun, Osypuk, & Emmons, 2005; Azagba & Shan, 2021; Wang et al., 2016). There is also agreement that the rates of combustible cigarette smoking increase with the time immigrants spend in the country. (Bethel & Schenker, 2005) The evolution in the rates of ENDS use by immigrants as they become acculturated to the U.S. however, is less clear (Azagba, Shan, & Latham, 2019; Bethel & Schenker, 2005; Kondo, Rossi, Schwartz, Zamboanga, & Scalf, 2016).

Current knowledge on smoking behaviors among Latino immigrants comes largely from research that has focused on immigrants that have been residing in the U.S for an extended period of time (Kaplan et al., 2014). Regarding recent immigrants, research recently conducted by this research team on a sample of Latino immigrants during the first year in Miami/Dade County (MDC) Florida confirmed that the smoking patterns of Latino immigrants during the first year in the U.S. are substantially influenced by their pre-immigration smoking patterns.(Sanchez et al., 2022). That study was part of an ongoing project funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to identify trajectories associated with impaired driving. Following a sample of recent Latino immigrants (RLIs) to MDC, this project collects annual information on the RLIs’ transportation patterns, their use of alcohol and other potentially impairing substances, as well as information on environmental, social, and contextual information that could be used to predict alcohol use and impair driving trajectories. Information on RLIs’ cigarette and ENDS use is annually collected as contextual information for the study. Our previous report examined RLIs’ patterns of cigarette use upon arrival to MDC (Sanchez et al., 2022). This present study extends that research and inform about the simultaneous use of cigarettes and ENDS by RLIs vary from pre-immigration to 2 years after arrival to MDC. Specifically, this study has three goals. The first aim (Aim 1) focuses on characterizing cigarette use. It has two accompanying sub-aims. Aim 1.a) was set to identify distinct smoking trajectories (number of days in the previous month in which the participant used cigarettes) among RLIs from pre-immigration (T0), first year in the U.S. (T1), to the second year in the U.S. (T2). Aim 1.b) to provide a characterization of group membership to cigarette trajectories according to basic demographic and socioeconomic indicators. Based on previous research showing that smoking rates among foreign-born Latinos/as increase as their time in the U.S. increases (Abraído-Lanza et al., 2005; Finch & Vega, 2003; Kaplan et al., 2014; Ornelas et al., 2011; Trinidad et al., 2011) we hypothesize an overall increase in RLI’s cigarette use during their second year in the country, with variation in this outcome associated by RLI’s income and education (i.e., lower income and lower education attainment associated with greater tobacco use). The second aim of this study (Aim 2) focuses on ENDS use. It also has two sub-aims. Aim 2.a) identifies distinct trajectories of ENDS use (number of days in the previous month in which the participant used ENDS). Based on previous reports (Wang et al., 2016), we hypothesize that RLIs’ use of ENDS increased from T0 to T2. Aim 2.b) provides a characterization of group membership to trajectories of ENDS use. Finally, Aim 3) explores a possible substitution effect between cigarette and ENDS.

Theoretical Framework

Theoretical foundations for the present study draw from acculturative stress theory (Berry, 2001) and segmented assimilation theory (Portes & Rumbaut, 2006; Portes & Rumbaut, 2014). The acculturative stress framework posits that stress can stem from challenges associated with the immigratory process which can cause adverse physical and mental health outcomes, including increased substance use, among immigrants (Berry, 2001). These sources of stress include socioeconomic strains, language and health care barriers, discrimination, and navigating new norms and values in their host culture (Sam & Berry, 2010). Segmented assimilation theory asserts that the process of immigrant assimilation to a host country may result in multiple forms of cultural adaptation (Eitle, Wahl, & Aranda, 2009). Acculturation trajectories leading to upward assimilation are associated with resources and strong ethnic enclave communities such as MDC that potentially insulate some immigrants from the negative influence of the risk behaviors of the dominant culture (Portes & Rumbaut, 2006; Portes & Rumbaut, 2014). Downward assimilation is often associated with economic disadvantage, a lack of resources, and negative experiences such and discrimination. By applying acculturative stress and segmented assimilation theory we hypothesized overall increases in cigarette smoking and ENDS use rates among RLIs with variations across income and education.

Materials and Methods

This study uses data from an on-going National Institutes of Health (NIH)-funded longitudinal study aimed to examine pre- to post-immigration trajectories of alcohol use and related outcomes among young adult RLIs aged 18-34 years old in MDC (Barton, Novoa, Sanchez, Romano, & Cano, 2021; Ramírez-Ortiz et al., 2021; Romano, Kelley-Baker, & Taylor, 2021; Romano, Lee, Babino, Taylor, & Sanchez, 2021; Sanchez et al., 2022; Westrick et al., 2022). Data, including added measures on tobacco use, were collected from November 2018 through December 2020. Retrospective pre-immigration data was obtained simultaneously with the current first-year post-immigration data (T0 and T1). A follow up assessment one year later collected data during RLIs second year in the U.S. (T2). During that second year, a COVID-19 lockdown was in place in Southern Florida. About half of the sample was interviewed during the lockdown. Inclusion criteria was determined by the parent study and involved being a Latino within a year of immigrating to the U.S from a Latin American country, with the intention to stay in the U.S. for at least 3-years beyond the initial assessment. Given that many RLIs had either temporary or undocumented immigration status, respondent-driven sampling was deemed the most appropriate sampling approach (Sanchez et al., 2022; Sanchez et al., 2014). Specifically, we asked each participant (the seed) to refer three individuals in his/her social network who met eligibility criteria. Seeds were recruited via fliers and in-person throughout MDC neighborhoods and businesses with substantial Latinx recent immigrant populations, community-based agencies serving Latinx recent immigrants, and during Latinx health fairs in Miami-Dade County. This procedure was followed for a maximum of three legs per seed.

Trained bilingual research staff conducted the surveys. Informed consent procedures were completed by all participants prior to data collection. Data were collected via Research Electronic Data Capture (REDCap) computer-assisted interviews through in-person interviews. Interviews conducted after the COVID-19 lockdown were administered remotely via phone. All surveys were administered in Spanish and completed at a confidential, safe location agreed upon by both the interviewer and participant. Each survey required approximately 1 ½ hours to complete. For their participation, participants received $50. A total of 540 immigrants were included in the study sample. This study was approved by the Institutional Review Board of the Social and Behavioral Institutional Review Board of Florida International University (Miami, FL).

A total of 540 RLIs were surveyed. Of them, only 529 provided information on tobacco use and were included in the sample. Participants were immigrants aged 18-34, with biological sex distributed relatively evenly between females and males, most of them have earned a high school diploma (only about 39% had a high school diploma or less), 62% of them were employed, a median last-month household income between $1,000 and $1,999. Approximately 18.4% of the sample consisted of undocumented immigrants. Sample distributions by national origin included 29 % Venezuelan, 33% Other South American, and 24% Central American, 9% Cuban, and 4% Other Latin American country. Compared to US Census data about foreign-born population of MDC (Atlas, 2018), there is an over representation of immigrants of Venezuelan descent in our sample, likely due to substantial increases in immigration from the region over the past decade (Sanchez et al., 2022).

Measures

Socio-demographics.

We measured participants’ age, sex, educational status level, household monthly income, whether the participant was employed; and country/region of origin. Participants also reported on their current immigration status in the U.S., with their answers coded: 1) “Permanent Resident”, either naturalized citizens or “green card” holders. 2) “Asylum seeker or asylum granted”, 3) “Temporary Resident”, e.g., international student, working permit; and 4) “Undocumented”, which includes individuals with illegal entry as well as those with an expired permit or visa.

Cigarette use.

To assess pre-migration smoking participants were asked: “before coming to the U.S. did you ever smoke cigarettes?” If “yes” a subsequent question asked: “In the last 30 days before coming to the U.S., on how many days did you smoke cigarettes?” An equivalent variable was created for post-immigration cigarette smoking by asking first year RLIs “since coming to the U.S. did you ever smoke cigarettes?” and second year RLIs “since our meeting about a year ago, did you ever smoke cigarettes?”. To those who answered “yes”, the following question was asked: “In the past 30 days, on how many days did you smoke cigarettes?”. Depending on the responses, RLIs were assigned to one of the following categories of cigarette use: “None”, “Low”, “Middle”, and “High” indicating no smoking at all; smoking between 1 and 6 days per month (d/m); between 7 d/m and 15 d/m, and between 16 d/m and 30 d/m, respectively.

ENDS.

To collect information on ENDS we followed a approach similar to the one described above. Similar questions to those described for smoking cigarettes were asked, with the term “smoke cigarettes” substituted by “use an e-cigarette or vape device, such as a e-pen, vape pen, or hookah?”.

Covid-19 Lockdown.

About 30% (N=157) of participants had been interviewed for the T2 follow up wave before the COVID-19 lockdown ordinances. Before the lockdown, RLIs were interviewed in person, at a secure, public location. RLIs who participated during the lockdown were interviewed remotely via phone. To account for the possible impact of the COVID-19 lockdown on participants’ tobacco use, a binary variable (0=before COVID-19 lockdown,1=after COVID 19 lockdown) was created to indicate whether the participant was interviewed before or after the lockdown.

Data Analyses

SAS®, v9.4 was used for all statistical analyses. Descriptive analyses and chi-square tests were conducted to assess and compare pre-immigration and post-immigration cigarette and ENDS use and their determinants. To establish trajectories of cigarette and ENDS use we first, identified those who had not smoked/used ENDS during the past month in any of the three time periods. They were assigned membership to the “non-users” trajectory. Next, we used the SAS® Trajectory Procedure (Proc Traj).(Jones, Nagin, & Roeder, 2001) to identify trajectories of “users”. Trajectory identification was conducted following the approach suggested by Arrendale and colleagues (2006), by gradually fitting models with increasing number of trajectories and group order (linear, quadratic, or cubic) (Arrandale, Koehoorn, MacNab, & Kennedy, 2006). Model selection was decided based on the Bayesian information criterion (BIC) and the practical importance of the selected trajectories (e.g., preference was given to robust models that could also identify among RLIs, those who increased cigarette use over time, as they a priori would be candidate for interventions). Next, we applied chi square tests and F-tests (for continuous variables) to examine and compare the demographic and socioeconomic characteristics of members of the identified trajectory groups. Next, we ran multilevel logistic regressions to assess the relative contribution (odds ratios, ORs) of the factors that tested significant in the bivariate analyses to each of the cigarette smoking and e-cigarette use trajectories. Finally, to assess Aim 3) we computed changes in the number of days RLIs smoked or used ENDS between T1 and T0, and T2 and T1, particularly noting those who decreased the use of cigarette but increased that of ENDS.

Results

Cigarettes

As shown in Figure 1, the overall mean number of days per month (d/m) RLIs smoked at each time period was relatively low (4.5 d/m, 3.8 d/m, and 1.9 d/m, at T0, T1, and T2, respectively). When only smokers were considered (i.e., after removing the never smokers), the mean number of days per month (d/m) smoked at T0, T1, and T2 was 11.8 d/m, 9.9 d/m, and 4.9 d/m, respectively. The smoking days rate at T2 was significantly lower than at either T0 or T1 (p<.05). This result contradicts and rejects our hypothesis that RLI’s cigarette use would increase during their second year in MDC.

Figure 1. Four Pre- to Post- Immigration Cigarette Use Trajectories.

Figure 1.

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“N-N-N”, “L-L-L”, “M-L-M” and “H-H-M” denote four trajectories of cigarette use, labeling the number of smoking days per month before immigration, during the first year, and second year in the U.S., respectively as No smoking (“N”), Low (“L”), Mid level (“M”) or High (“H”). “Overall” rates indicate the mean number of days per month as reported by all RLIs in the sample (including non-smokers). The “Smokers Only” rates show the mean number of days per month reported only by smokers (i.e., after excluding RLIs in the “N-N-N” group). “*” denotes statistical significance (p<.05) between the pre-immigration and second year smoking rates

In line with our previous report (Sanchez et al., 2022), RLIs’ rates of smoking days did not change much during the first year in MDC from before immigration: 3 out of the 4 trajectories indicated similar T0 – T1 smoking rates (“N-N-N”, “L-L-L”, and “H-H-M”). Overall, four trajectories of cigarette use were identified. Most RLIs (61.8%) reported not smoking cigarette at all, and another 16.3% smoked less than 6 days a month in any of the 3 time periods (“N-N-N” and “L-L-L” trajectories, respectively). About 10.6% of RLIs showed a reduction in smoking days between T0 and T1 (those in the “M-L-M” trajectory). One year later (at T2), most RLIs kept consistent rates in smoking days compared to T1, but 11.3% showed a significant decrease in smoking days from 26.6 d/m in T1 to 9.7 d/m in T2.

Table 1 shows the distribution of demographic and socioeconomic characteristics of RLIs’ in the four trajectories of cigarette use. Compared to males, females were more likely to be members of the non-smokers trajectory (“N-N-N”) but less likely to be members of the trajectories with higher number of smoking days (“M-L-M” and “H-H-M”). RLIs’ income increased over time, with the percentage who earned less than $2,000 a month decreasing from T0 (82%) to T1 (63%), and T2 (48%). While income in the country of origin (T0) did not explain membership across any trajectory, the large majority (70.8%) of those who earned $4,000 or more per month at T2 were members of the non-smokers trajectory (“N-N-N”). Most RLIs (54%) arrived with a temporary permit (other than asylum). RLIs’ legal residency status did not change significantly between T1 and T2 (not shown in Table 1). Asylum seekers and those with a temporary residency status were less likely to follow a “H-H-M” smoking trajectory than permanent residents or those with undocumented immigration status. The RLIs in the sample were relatively highly educated. Approximately 61% of them studied beyond High School. Those who did not graduate from High School were more likely to follow the “H-H-M” trajectory than RLIs with higher educational achievement. About half of the participants were single/lived without a spouse or partner, and half were married/lived with a partner. Most RLIs (72%) had no children. Those with no children were more like to follow the “L-L-L” trajectory. Compared with those who were employed, RLIs who were not employed at T2 were more likely to follow the “L-L-L” trajectory.

Table 1.

Demographic and Socieconomic Characteristics of Members of the Four trajectories of Cigarette Use

N Col% N-N-N L-L-L M-L-M H-H-M p value
Sex Men 268 (51%) 49.6% 17.5% 16.8% 16.0% <.0001
Women 260 (49%) 74.2% 15.0% 4.2% 6.5%
Age at T1 18-20 68 (13%) 57.4% 27.9% 5.9% 8.8% 0.1873
21-24 98 (19%) 59.2% 17.4% 9.2% 14.3%
25-29 138 (26%) 65.9% 13.8% 8.7% 11.6%
30-34 224 (42%) 61.6% 13.8% 13.8% 10.7%
Monthly Income at T0 < $2000 424 (82%) 61.6% 16.8% 10.4% 11.3% 0.8623
$2000-$3999 72 (14%) 62.5% 15.3% 12.5% 9.7%
$4000 or more 24 (5%) 54.2% 12.5% 12.5% 20.8%
Monthly Income at T1 < $2000 328 (63%) 62.8% 19.2% 8.2% 9.8% 0.0503
$2000-$3999 171 (33%) 57.9% 11.7% 15.2% 15.2%
$4000 or more 22 (4%) 63.6% 13.6% 13.6% 9.1%
Monthly Income at T2 < $2000 253 (48%) 58.9% 21.3% 7.9% 11.9% 0.0039
$2000-$3999 249 (47%) 63.5% 11.7% 14.5% 10.4%
$4000 or more 24 (5%) 70.8% 12.5% 0.0% 16.7%
Legal Residency Status Permanent Resident 86 (16%) 57.0% 16.3% 5.8% 20.9% 0.0062
Undocumented 96 (18%) 61.5% 11.5% 8.3% 18.8%
Temporary 284 (54%) 61.3% 18.7% 13.0% 7.0%
Asylum 57 (11%) 70.2% 12.3% 10.5% 7.0%
Education < High School 19 (4%) 47.4% 10.5% 0.0% 42.1% 0.0015
High School Diploma 188 (36%) 56.9% 17.0% 11.7% 14.4%
> High School 320 (61%) 65.3% 16.3% 10.6% 7.8%
Marital Status Single/Lived Alone 280 (53%) 58.2% 21.4% 7.9% 12.5% 0.0007
Married/Partner 246 (47%) 65.9% 10.2% 13.8% 10.2%
Has at least 1 child Yes 148 (28%) 72.3% 10.1% 7.4% 10.1% 0.0096
No 376 (72%) 57.5% 18.9% 11.7% 12.0%
Employed at T1. Yes 323 (61%) 60.7% 14.6% 9.6% 15.2% 0.003
No 203 (39%) 63.6% 18.7% 12.3% 5.4%
Employed at T2. Yes 402 (76%) 62.9% 13.7% 10.2% 13.2% 0.0052
No 126 (24%) 57.9% 24.6% 11.9% 5.6%
Country of Origin Venezuela 155 (29%) 67.1% 15.5% 9.0% 8.4% 0.3343
Other South American 175 (33%) 55.4% 21.1% 12.0% 11.4%
Central American 126 (24%) 63.5% 12.7% 10.3% 13.5%
Other 71 (13%) 63.4% 12.7% 9.9% 14.1%
Assessment Timepoint at T2 Before COVID 19 lockdown 157 (30%) 64.3% 13.4% 12.7% 9.6% 0.374
During COVID 19 lockdown 369 (70%) 60.4% 17.6% 9.8% 12.2%
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“N-N-N”, “L-L-L”, “M-L-M” and “H-H-M” denote four trajectories of cigarette use, labeling the number of smoking days per month before immigration, during the first year, and second year in the U.S., respectively as No smoking (“N”), Low-level (“L”), Mid-level (“M”) or High-level (“H”).

Table 2 shows the odds ratio (OR) estimates obtained from the multilevel logistic regressions. Relative low education (less than HS) was a highly significant factor associated with RLIs membership to the “H-H-M” trajectory (OR=8.25). Sex was also an important factor to explain RLIs smoking trajectories. RLIs’ males were more likely than females to be member of the “H-H-M” or “M-M-L” trajectories than to the non-smoking (“N-N-N”) trajectory (OR=3.58, and OR=5.31, respectively). RLIs with a temporary residency status were less likely to follow the “H-H-M” trajectory than those without papers (OR=0.34). RLIs who were employed at T2 were less likely to be members of the “L-L-L” than the “N-N-N” trajectory.

Table 2.

Distribution of Demographic and Socioeconomic factors Associated with RLI’s trajectories of Cigarette use

Trajectory. Ref: N-N-N Effect OR 95% CI
LLL Legal Residence Status Asylum 1.24 0.42 3.69
Permanent Resident 1.86 0.72 4.80
Temporary 1.88 0.87 4.04
Ref: Without Papers
Education HS Diploma 1.09 0.63 1.86
Less than HS 0.50 0.09 2.70
Ref: Some training/college after HS
Employment at T1. Employed 1.04 0.58 1.87
Ref: Unemployed
Employment at T2. Employed 0.49 0.27 0.91
Ref: Unemployed
Marital Status Married/Partner 0.58 0.33 1.04
Ref: Single/Lived Alone
Income at T1 $2000 - $3999 0.67 0.35 1.26
$4000 or more 0.82 0.21 3.19
Ref: Less than $2000
Income at T2 $2000 - $3999 0.62 0.35 1.11
$4000 or more 0.85 0.22 3.29
Ref: Less than $2000
Has at least 1 child Yes 0.44 0.22 0.89
Ref: No
Sex Male 1.61 0.96 2.72
Ref: Female
MLM Legal Residence Status Asylum 0.80 0.23 2.78
Permanent Resident 0.94 0.27 3.33
Temporary 1.07 0.44 2.62
Ref: Without Papers
Education HS Diploma 1.14 0.59 2.21
Less than HS
Ref: Some training/college after HS
Employment at T1. Employed 0.63 0.30 1.32
Ref: Unemployed
Employment at T2. Employed 0.66 0.29 1.47
Ref: Unemployed
Marital Status Married/Partner 2.03 1.03 4.01
Ref: Single/Lived Alone
Income at T1 $2000 - $3999 1.63 0.78 3.41
$4000 or more 1.38 0.32 5.88
Ref: Less than $2000
Income at T2 $2000 - $3999 1.50 0.73 3.09
$4000 or more
Ref: Less than $2000
Have at least 1 child Yes 0.47 0.21 1.04
Ref: No
Sex Male 5.31 2.55 11.07
Ref: Female
HHM Legal Residence Status Asylum 0.29 0.08 1.01
Permanent Resident 1.19 0.51 2.80
Temporary 0.34 0.15 0.75
Ref: Undocumented
Education HS Diploma 1.70 0.89 3.23
Less than HS 8.25 2.35 28.95
Ref: Some training/college after HS
Employment at T1. Employed 1.88 0.82 4.33
Ref: Unemployed
Employment at T2. Employed 1.84 0.68 4.95
Ref: Unemployed
Marital Status Married/Partner 0.76 0.39 1.49
Ref: Single/Lived Alone
Income at T1 $2000 - $3999 1.76 0.86 3.60
$4000 or more 1.31 0.25 6.90
Ref: Less than $2000
Income at T2 $2000 - $3999 0.85 0.42 1.72
$4000 or more 1.60 0.44 5.83
Ref: Less than $2000
Has at least 1 child Yes 0.70 0.33 1.49
Ref: No
Sex Male 3.58 1.86 6.92
Ref: Female
Open in a new tab

“N-N-N”, “L-L-L”, “M-L-M” and “H-H-M” denote four trajectories of cigarette use, labeling the number of smoking days per month before immigration, during the first year, and second year in the U.S., respectively as No smoking (“N”), Low-level (“L”), Mid-level (“M”) or High-level (“H”). “OR” stands for odds ratio. “95% CI” stands for 95% confidence interval for OR. Cells in bold denote ORs significantly different from OR=1. Cells in grey indicate a sample too small for meaningful comparisons.

ENDS

We also identified four trajectories of ENDS (Figure 2). They are labeled as None-None-None (N-N-N), Low-Low-Low (L-L-L), Low-Middle-High (L-M-H), and Middle-Middle-Low (M-M-L). Compared to the number of days they used cigarettes, RLIs used ENDS during less number of days. Unlike the overall decline in the use of cigarettes (Figure 1), the overall number of days RLIs used ENDS did not change over time. The number of days RLIS used ENDS actually increased (not statistically significant) during the first year in MDC when only users were considered (i.e., after removing those in the “N-N-N” group). Nevertheless, RLIs use of ENDS returned to the T1 levels during the second year in MDC. As with cigarettes, most RLIs (73.4%) did not use ENDS, and another 15.9% used it less than 6 days a month in any of the 3 time periods assessed (the “N-N-N” and “L-L-L” trajectories, respectively).

Figure 2. Four Pre- to Post- Immigration ENDS Use Trajectories.

Figure 2.

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“N-N-N”, “L-L-L”, “L-M-H” and “M-M-L” denote four trajectories of ENDS use, labeling the number of days per month RLIs used ENDS before immigration, during the first year, and second year in the U.S., respectively as No smoking (“N”), Low (“L”), Mid level (“M”) or High (“H”). “Overall” rates indicate the mean number of days per month as reported by all RLIs in the sample (including non-users). The “ENDS users only” rates show the mean number of days per month reported only by ENDS users (i.e., after excluding RLIs in the “N-N-N” group).

Table 3 shows the demographic and socioeconomic characteristics shown by RLIs over the four trajectories of ENDS use. As with cigarette use, females were more likely than males to follow the “N-N-N” trajectory of ENDS use. Although RLIs’ age was not significantly associated with cigarette trajectories, age was a factor behind trajectories of ENDS use. While most RLIs aged 25 years old or older reported never using ENDS (i.e., members of the “N-N-N’ trajectory), those younger than 25 years of age were overrepresented among ENDS users. Membership to the increasing “L-M-H” trajectory was also more likely for those earning less than $2,000 at T1, were married/living with a partner,, did not have children, and were employed at T1.

Table 3.

Distribution of Demographic and Socioeconomic Characteristics Across Members of the Four trajectories of ENDS Users

N Col% N-N-N L-L-L L-M-H M-M-L p value
Sex Men 266 (51%) 63.9% 6.4% 19.2% 10.5% 0.0001
Women 258 (49%) 71.3% 2.7% 23.6% 2.3%
Age 18-20 68 (13%) 47.1% 11.8% 30.9% 10.3% <.0001
21-24 96 (19%) 47.9% 7.3% 34.4% 10.4%
25-29 136 (26%) 71.3% 2.9% 16.9% 8.8%
30-34 224 (43%) 79.9% 2.2% 15.6% 2.2%
Monthly Income at T0 < $2000 422 (63%) 69.2% 4.5% 21.1% 5.2% 0.0662
$2000-$3999 71 (33%) 63.4% 2.8% 23.9% 9.9%
$4000 or more 24 (4%) 50.0% 12.5% 16.7% 20.8%
Monthly Income at T1 < $2000 328 (63%) 68.3% 3.1% 25.3% 3.4% 0.0003
$2000-$3999 171 (33%) 66.1% 6.4% 15.2% 12.3%
$4000 or more 22 (4%) 63.6% 13.6% 13.6% 9.1%
Monthly Income at T2 < $2000 252 (48%) 69.1% 4.4% 23.0% 3.6% 0.0842
$2000-$3999 248 (47%) 67.7% 4.4% 19.0% 8.9%
$4000 or more 23 (4%) 47.8% 8.7% 30.4% 13.0%
Legal Residency Status Permanent 86 (17%) 64.0% 5.8% 24.4% 5.8% 0.3500
Undocumented 96 (18%) 69.8% 3.1% 24.0% 3.1%
Temporary 282 (54%) 66.3% 5.0% 19.9% 8.9%
Asylum 57 (11%) 75.4% 3.5% 19.3% 1.8%
Education < HS 19 (4%) 57.9% 0.0% 42.1% 0.0% 0.1627
HS Diploma 187 (36%) 66.3% 4.8% 20.3% 8.6%
> HS 317 (61%) 68.8% 4.7% 20.8% 5.7%
Marital Status Single/Lived Alone 244 (51%) 75.0% 4.5% 14.3% 6.2% 0.0019
Married/Partner 279 (49%) 60.9% 4.7% 27.6% 6.8%
Have at least 1 child Yes 148 (49%) 85.1% 1.4% 8.8% 4.7% <.0001
No 372 (51%) 60.5% 5.9% 26.3% 7.3%
Employed at T1 Yes 323 (62%) 62.2% 5.6% 24.8% 7.4% 0.0085
No 199 (38%) 76.4% 3.0% 15.6% 5.0%
Employed at T2 Yes 399 (62%) 67.9% 5.0% 21.1% 6.0% 0.7048
No 125 (38%) 66.4% 3.2% 22.4% 8.0%
Country of Origin Venezuela 153 (29%) 57.5% 7.8% 24.8% 9.8% 0.1027
Other South American 174 (33%) 68.4% 4.0% 23.6% 4.0%
Central American 126 (24%) 75.4% 2.4% 15.1% 7.1%
Other 70 (13%) 72.9% 2.9% 20.0% 4.3%
Assessment Timepoint at T2 Before COVID 19 lockdown 155 (30%) 63.9% 3.9% 25.8% 6.5% 0.4645
During COVID 19 lockdown 367 (70%) 68.9% 4.9% 19.6% 6.5%
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“N-N-N”, “L-L-L”, “M-L-M” and “H-H-M” denote four trajectories of ENDS use, labeling the number of days per month before immigration, during the first year, and second year in the U.S., respectively as No use of ENDS (“N”), Low-level use (“L”), Mid-level use (“M”) or High-level use (“H”).

Table 4 shows the ORs obtained by the multivariate regression modeling the contribution of the factors associated with the ENDS trajectories. As suggested by the bivariate analyses, age was a significant factor explaining membership to ENDS trajectories. Membership in the trajectory showing a continuous increase in ENDS use (“L-M-H”) was more likely among RLIs 21-24 years old (compared to those aged 30-34), males, those employed at T1, did not have children, and those who in the country of origin earned less than $2,000 a month. Sex (being male) and age (being younger than 25 years old) were the only factors that were consistently significant in explaining membership to the low ENDS user trajectory (“L-L-L”) rather than the non-users trajectory (“N-N-N”). As with cigarettes, the role of income in determining trajectories of ENDS use is unclear. No clear pattern emerges other than those who used ENDS in their country of origin tended to earn more than $2,000 a month. It could be argued that the main engine behind the use of ENDS after immigration relates to its use as substitute for cigarette smoking. This possibility is presented next.

Table 4.

Demographic and Socioeconomic Factors Associated with RLI’s trajectories of ENDS Use

Trajectory.
Ref: N-N-N 		Effect OR 95% CI
L-L-L Age 18-20 8.76 2.11 36.31
21-24 7.74 1.97 30.41
25-29 1.22 0.30 4.93
Ref: 30-34
Employment at T1 Employed 2.11 0.74 5.99
Ref: Unemployed
Marital Status Married/Partner 2.48 0.87 7.07
Ref: Single/Lived Alone
Monthly Income at T0 $2000 - $3999 0.53 0.11 2.60
$4000 or more 2.32 0.46 11.72
Ref: Less than $2000
Monthly Income at T1 $2000 - $3999 1.50 0.53 4.20
$4000 or more 4.41 0.73 26.65
Ref: Less than $2000
Monthly Income at T2 $2000 - $3999 0.66 0.24 1.84
$4000 or more 1.15 0.18 7.32
Ref: Less than $2000
Has at least 1 child Yes 0.24 0.05 1.15
Ref: No
Sex Male 3.12 1.15 8.48
Ref: Female
L-M-H Age 18-20 2.10 0.98 4.47
21-24 2.69 1.38 5.23
25-29 1.06 0.56 1.98
Ref: 30-34
Employment at T1 Employed 2.41 1.43 4.04
Ref: Unemployed
Marital Status Married/Partner 0.64 0.37 1.10
Ref: Single/Lived Alone
Monthly Income at T0 $2000 - $3999 0.44 0.24 0.78
$4000 or more 0.63 0.15 2.62
Ref: Less than $2000
Monthly Income at T1 $2000 - $3999 1.46 0.74 2.88
$4000 or more 1.16 0.33 4.09
Ref: Less than $2000
Monthly Income at T2 $2000 - $3999 1.04 0.62 1.75
$4000 or more 2.05 0.66 6.38
Ref: Less than $2000
Has at least 1 child Yes 0.33 0.17 0.68
Ref: No
Sex Male 1.12 0.69 1.81
Ref: Female
M-M-L Age 18-20 6.93 1.74 27.66
21-24 9.16 2.60 32.19
25-29 4.21 1.36 13.01
Ref: 30-34
Employment at T1 Employed 1.22 0.49 3.03
Ref: Unemployed
Marital Status Married/Partner 1.10 0.45 2.71
Ref: Single/Lived Alone
Monthly Income at T0 $2000 - $3999 1.41 0.49 4.04
$4000 or more 4.74 1.24 18.10
Ref: Less than $2000
Monthly Income at T1 $2000 - $3999 1.84 0.73 4.65
$4000 or more 1.10 0.17 7.34
Ref: Less than $2000
Monthly Income at T2 $2000 - $3999 1.75 0.69 4.42
$4000 or more 3.89 0.80 19.06
Ref: Less than $2000
Has at least 1 child Yes 0.85 0.31 2.35
Ref: No
Sex Male 5.51 2.09 14.54
Ref: Female
Open in a new tab

“N-N-N”, “L-L-L”, “L-M-H”, and “M-M-L” denote four trajectories of ENDS use, labeling the number of days per month before immigration, during the first year, and second year in the U.S., respectively as No use of ENDS (“N”), Low use (“L”), Mid-level use (“M”), or High-level use (“H”). “OR” stands for odds ratio. “95% CI” stands for 95% confidence interval for OR. Cells in bold denotes ORs significantly different from OR=1.

Assessing Cigarette/ENDS Substitution

Table 5 shows the percent of RLIs who increased, maintained, or decreased cigarette and ENDS use between periods. As suggested by the study findings, the large majority of RLIs (about 73%) did not alter their cigarette smoking or ENDS use between T0 and T1. Of special interest where those who decreased the use of cigarette while increasing their use of ENDS. Of the 90 RLIs who reduced cigarette use between T0 and T1, 21 (23%) reported an increase in ENDS use. One year later, of the 104 who reduced cigarette use between T1 and T2, 8 (8%) increased the use of ENDS. Subsequently, the low number (and proportion) of RLIs who have reduced the use of cigarette while increased that of ENDS suggests that overall, no substitution of ENDS for cigarette use took place.

Table 5.

Percent of RLIs who increased, maintained, or decreased Cigarette & ENDS Use between Periods

Between T0 and T1
ENDS Use
N Col% Decreased Same Increased
Cigarette Use Decreased 90 (17%) 23% 53% 23%
Same 383 (73%) 7% 81% 13%
Increased 54 (10%) 15% 48% 37%
All 527 (100%) 10.2% 72.7% 17.1%
Between T1 and T2
ENDS Use
N Col% Decreased Same Increased
Cigarette Use Decreased 104 (20%) 43% 49% 8%
Same 384 (73%) 13% 82% 5%
Increased 39 (7%) 23% 56% 21%
All 527 (100%) 19.9% 73.6% 6.5%
Open in a new tab

The top half of the Table shows the percentage of RLIs who decreased, maintained, or increased cigarette use between T0 and T1 and simultaneously decreased, maintained, or increased ENDS use. For instance, of the 90 RLIs who decreased cigarette use between T0 and T1, 23% of them also decreased the use of ENDS. The bottom half of the table shows similar distribution but for the T1 and T2 period. Cells in bold denote the percentage of RLIs who may have substituted cigarette by ENDS use at each period.

It should be noted, that, a small number of RLIs reduced cigarette use while simultaneously increasing ENDS use. However, the small number of participants in this category precluded any further detailed and statistical exploration. Table 5 shows the distribution of three characteristics of these few RLIs depart sharply from the study sample as a whole. These characteristics were sex (62% and 75% of the RLIs who may have substituted cigarettes for ENDS between T0 and T1, and T1 and T2, respectively, were men); age (24% and 38% of those who substituted cigarettes for ENDS between T0 and T1 and T1 and T2, respectively, were aged 18-20), and income, although only at T1 (substitution was less likely to occur among those who earned less than $2,000 a month).

Discussion

Cigarettes

In our previous examination of RLIs during their first year in MDC, we reported that RLIs’ smoking rates upon arrival to the U.S. were highly influenced by the smoking rates in their country of origin (Sanchez et al., 2022). Results from the present study reflect this previous finding by reporting that about 73% of the RLIs showed smoking levels in T1 similar to those in T0. This study was set to investigate what happened one year later. Acculturative stressors including economic insufficiency and unemployment, as well as undocumented immigration status, had been shown to induce an escalation in tobacco use after immigration, particularly among women) (Kaplan et al., 2014; Marin, Perez-Stable, & Marin, 1989; Wilkinson et al., 2005). Subsequently, we hypothesized that cigarette use among RLIs to MDC would increase at T2. Contrary to our hypotheses, study findings revealed decreases in cigarette use.

This decline could be attributed, at least in part, to the demographic and populational characteristics of the Latino/a immigrant community in MDC. Research on the escalation in tobacco use among Latino/a immigrants to the U.S. has been largely conducted with Mexican immigrant populations (Borges et al., 2011; Worby & Organista, 2013). In 2000, about 25% of the Latino/a immigrants to southern Florida came from Cuba (Bankston III, 2007). Over the past decade, a shift in Latino/a immigration patterns to MDC have taken place, leading to steep increases in immigrants from Venezuela (Sanchez et al., 2022). Relatively high-educated (approximately half of Venezuelans in the US were college graduates) (Vos et al., 2022), the RLIs from Venezuela may be less inclined to use tobacco than other less educated RLIs.

RLIs’ continuous decline in cigarette use may also be explained by characteristics unique to the MDC. Compared with other immigrant-receiving communities in the U.S., MDC offers a higher supportive bicultural environment (Sanchez et al., 2014) which may have reduced acculturation stress and the need for RLIs to use tobacco and other substances as coping mechanisms (Cano et al., 2018; Levitt et al., 2019; Sanchez et al., 2016).

Despite the soundness of these arguments in explaining the overall decline in cigarette use over time, the sharp decline in cigarette use registered between T1 and T2 warrants further examination. We speculate that such a sharp decline may be related to the COVID-19 pandemic. Although we tested and found no differences in the responses provided by RLIs who at T2 participated before and during MDC pandemic lockdown, it could be argued that the ominous arrival of the pandemic may have had an impact on RLIs’ tobacco use even before the lockdown was mandated. However, this argument does not fit well with the theoretical background in which this study is based. Based on our theoretical framework, rather than a decrease we would have expected an increase in tobacco use motivated by the need to cope with pandemic stress. It is possible that the concern our sample of RLIs may have had for the pandemic did not outweigh the benefits they associated with immigration. Many of the RLIs in the sample experienced a forced migration. The relief they felt upon arrival to MDC, including the unique support the region provides to RLIs, may have overcome negative experiences associated with the pandemic lockdown. This explanation, however, is highly speculative and in need of further research. Research is needed to clarify these issues, as they are key to determining whether the decline in tobacco use documented by this study is temporary or permanent, and if the former, to understand the mechanisms that would make the decline permanent.

Of special interest are the RLIs who followed a trajectory that started with high rates of smoking (the “M-L-M” and “H-H-M” trajectories). These RLIs tended to be males, with relatively low educational achievement, and/or unemployed. This finding is not surprising as the literature consistently links these factors with elevated smoking rates (Garrett et al., 2011; B. E. Garrett, B. N. Martell, R. S. Caraballo, & B. A. King, 2019). Less clear was the role of income. Although the literature has also linked elevated smoking rates with low-income (Flint & Novotny, 1997; Garrett et al., 2011; Bridgette E Garrett, Brandi N Martell, Ralph S Caraballo, & Brian A King, 2019), in this study the role of income on trajectory membership was less clear. Before immigration, income was not a factor significantly associated with the trajectories of cigarette smoking. Upon arrival to MDC (at T1), not only the low-income RLIs, but also those high-income were overrepresented among “Heavy” smokers (those in the “H-H-M” trajectory). The overrepresentation of high-income RLIs among heavy smokers may seem at first sight unexpected. Past research has shown that in some Latin American countries smoking rates have been found to be high not only among individuals of low socioeconomic status (SES), but also among elevated SES (Joly, 1975), particularly women (Tong, Turcios-Ruiz, Dietz, & England, 2011). Our earlier analysis of this sample (Sanchez et al., 2022), confirmed by this study, showed that upon arrival to MDC, RLIs tend to maintain the smoking patterns they use in the countries of origin.

Thus, while upon arrival to MDC RLIs tended to maintain their previous smoking behaviors, as their time in MDC increased, income became increasingly relevant in defining smoking trajectories. We speculate that the increasing importance of income on cigarette use over time paralleled a decrease in RLIs’ perception of smoking as an acceptable behavior. In efforts to prevent poor health outcomes, smoking has become stigmatized in the U.S. in a way that has not yet occurred in Latin American countries (Chung & Ahn, 2013; Lyvers, Hall, & Bahr, 2009). Facing social unacceptability, RLIs who were smokers before immigration may have been inclined to reduce the use of cigarettes after immigration, a process that could have slowly erode the smoking patterns they brought from their countries of origin. This process may have been faster for RLIs who experienced a large increase in income after immigration. Due to their increased income, these RLIs may have been less susceptible to immigration stress and could have had a reduced need to use cigarettes as a coping mechanism. Although speculative, this argument underscores the importance of 1) prevalent values and perceptions towards cigarette smoking in both the countries of origin and the hosting immigrant communities, and 2) the need to identify the mechanisms that could facilitate the acceptance of healthier behaviors among RLIs when values and perceptions are shifting.

The present study also describes and characterizes RLI’s early trajectories of ENDS use. Unlike the rates of cigarette use, which consistently decreased between T0 and T2, ENDS use showed an increase between T0 and T1, followed by a decrease to T0 levels a year later. The opposing directions in which cigarette and ENDS use shift from T0 to T1 seems to suggest a substitution behavior between these products after immigration. However, the decrease in both cigarette and ENDS use between T1 and T2 suggests such a substitution hypothesis should be rejected. A closer examination of this hypothesis showed that among RLIs who reduced the days they smoked between T0 and T1, only 23% reported an increase in ENDS use during that same time period. One year later, only 8% of those who decreased cigarette use between T1 and T2 reported an increase in ENDS use. Although these results further ratify the rejection of the substitution hypothesis, they do not negate that such a substitution may have taken place for some RLIs, particularly among younger aged males. In any case, research is needed to determine whether the patterns of tobacco use (cigarettes and/or ENDS) documented by this study are temporary or permanent, and if the former, to understand the mechanisms that would facilitate making these decline permanent.

Limitations

Results from this study should be interpreted in light of several limitations. Although respondent-driven sampling is a preferred method to recruit “hard to reach” populations, such as recent and undocumented immigrants, it does not ensure a representative sample. Pre-immigration cigarette and e-cigarette use were collected retrospectively, making this information susceptible to recall errors. Another important limitation of this study is that while it examined changes in the frequency of cigarette and e-cigarette use, failed to also consider the quantity that was consumed in those days. Also, the study did not account for the role that MDC policies such as smoking bans in public and/or private places may have on post-immigration smoking patterns. Future studies with larger sample sizes are needed to address these limitations, assess how patterns of cigarette and ENDS use evolve over time, and examine such evolution in parallel to that of other substances (i.e., alcohol). Finally, although this study found no impact of the COVID-19 lockdown on participants’ responses at T2, it is possible that such effects may have become evident as time advanced further into the pandemic. As such, future research should also aim to assess whether the initial negligible impact of the COVID-19 pandemic on RLIs’ cigarette and e-cigarette increases in significance over time.

Conclusion

While RLIs’ overall decrease in smoking rates is encouraging, there is a need to understand the mechanisms behind such a decrease in order to prevent smoking rates from reverting back to pre-immigration levels as time in the U.S. increases. Indeed, this pattern of initial decreases in substance use during the first several years in the U.S. among RLIs followed by subsequent increases over time has been found for alcohol use (De La Rosa, Sanchez, Wang, Cano, & Rojas, 2020). It remains to be seen if the same holds true to tobacco use. Future longitudinal examination of smoking patterns among RLIs are necessary to identify these potential trajectories. Similarly, there is a need to further understand patterns of ENDS use among RLIs, in particular whether they are used as substitute for cigarette smoking. Finally, although the impact of the COVID-19 pandemic on cigarette and/or ENDS use by the RLIs to MDC may have been minimal, there is a need to assess any long-term impact the pandemic may be having on this population.

Acknowledgements

This work was supported by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health under Grant Number R01AA025720 - 01A1. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

Declaration of interest

The authors report there are no competing interests to declare.

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