Abstract
This paper examines patterns of smoking cessation among Hispanics/Latinos with particular attention to gender, acculturation, and national background. Data are from the Hispanic Community Health Study/Study of Latinos, a population-based study of 16,415 non-institutionalized Hispanics/Latinos ages 18–74 from a stratified random sample of households in Chicago, Miami, the Bronx, and San Diego. Face-to-face interviews, in English or Spanish, were conducted from 2008–2011. Findings are based on 6,398 participants who reported smoking at least 100 cigarettes in their lifetime. Associations with smoking cessation outcomes were assessed in bivariate and multivariable analyses. Findings indicate that approximately equal proportions of men and women were former smokers. There was little difference by gender in socioeconomic characteristics associated with smoking cessation. Both men and women who lived in households with smokers were less likely to be abstinent. Multivariable analysis indicated that the likelihood of quitting varied by national background primarily among men. Puerto Rican and Cuban smokers of both genders were the least likely to successfully quit smoking. Among women, but not men, younger and more socially acculturated individuals had lower odds of sustaining cessation. Over 90% of female and male former smokers reported quitting on their own without cessation aids or therapy. The results suggest that many Hispanics/Latinos are self-motivated to quit and are able to do so without clinical assistance. Heterogeneity in smoking behaviors among Hispanics/Latinos should be taken into account when developing and delivering smoking cessation interventions and public health campaigns.
Keywords: Latinos, smoking cessation, acculturation, gender
INTRODUCTION
The prevalence of cigarette smoking in the United States continues to decline across race and ethnic groups. However, one out of seven U.S. Hispanics/Latinos used cigarettes in 2013.1 Although smoking prevalence among Hispanics/Latinos is lower than the national average, much of the recent U.S. population growth is attributable to increasing numbers of Hispanics/Latinos 2 and smoking-related illnesses are leading causes of death among this population group.3 Thus, reducing tobacco use by Hispanics/Latinos is a significant public health issue. The importance of promoting smoking cessation among Hispanics/Latinos is underscored by evidence that they are less likely than other ethnic groups to be advised to quit by health professionals or to use tobacco cessation aids.4–6
National data from 2003 indicate that among those who ever smoked, Hispanics/Latinos were less likely to be former smokers compared to non-Hispanic Whites.6 In 2010, fewer U.S. Hispanic/Latino smokers expressed an interest in quitting compared to non-Hispanic Blacks and non-Hispanic Whites.7 Overall statistics mask variation across U.S. Hispanic/Latino subgroups in smoking prevalence, which is highest among Puerto Rican and Cuban-American men and women.8–10 However, few national studies examine Hispanic/Latino smoking cessation by national background. One such study indicated that relatively more Puerto Rican men and women were former smokers compared to those of Cuban and Mexican background.11 Although the low prevalence of smoking by Hispanic/Latina women is a consistent finding,12–17 only a small number of studies have examined the relationship between gender and smoking cessation among Hispanics/Latinos.11,15,17,18
A well-established finding is the association of acculturation, the adoption by immigrants of values, attitudes, and behaviors of the surrounding new culture, with increased probability of smoking among Hispanics/Latinos, particularly women.10,15,17,19–24 This relationship is generally similar to that found among U.S. black and Asian immigrants, who also have lower prevalence of smoking compared with whites or those born in the U.S.25,26 However, there is some evidence that acculturation has a positive association with smoking among Latina and Asian women, with the opposite pattern among men.17,27,28 The few studies examining the relationship of acculturation to smoking cessation yield inconsistent results.15,29,30 Less acculturated U.S. Hispanics/Latinos may have greater concerns about the effects of smoking on others, especially family members,31 as well as lower nicotine dependency and more infrequent use of nicotine replacement therapy.32
The objective of this paper is to characterize smoking cessation in a large and diverse population-based sample of Hispanics/Latinos living in four U.S. metropolitan areas with high concentrations of Hispanics/Latinos. The focus is on examining how smoking cessation is related to sociodemographic characteristics, smoking behaviors and influences, and quit attempts, with particular attention to patterns by gender, national background, and acculturation.
METHODS
Sampling Design
Data are from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), a population-based study of Hispanics/Latinos from randomly selected households in Chicago, Miami, the Bronx, and San Diego. U.S. Hispanic/Latinos are defined as persons residing in the United States who have personal or family roots in the Spanish-speaking nations of Latin America. The target population was non-institutionalized Hispanics/Latinos ages 18–74 years residing in defined geographic areas who self-identified as Hispanic/Latino and were able to travel to a local study field center. HCHS/SOL includes individuals of various national backgrounds, the largest being Mexican (n=6,471), Puerto Rican (n=2,728), Cuban (n=2,348), Central American (n=1,730), Dominican (n=1,460), and South American (n=1,068).
Participants were selected based on a stratified two-stage area probability sample of household addresses from each of the field sites. The first stage randomly selected census block groups with stratification based on Hispanic/Latino concentration and proportions of high or low level of education. The second stage randomly selected households from census block groups. Oversampling was employed to increase the likelihood of identifying Hispanic/Latino households and representation of adults older than 45 years of age, relating to the main study’s interest in examining chronic diseases. In-person or telephone contacts were made to screen eligible households. Sampling design and selection is described in detail elsewhere.33
Baseline interviews were conducted in English or Spanish from 2008–2011.34 Of 39,384 individuals who met eligibility criteria, 41.7% were enrolled, representing 16,415 persons from 9,872 households. The study was approved by Institutional Review Boards at each field center, where all participants gave written consent.
Variables and Measures
All variables are based on self-reports. Smoking status was assessed by the question “Have you ever smoked at least 100 cigarettes in your entire life?” Participants responding “yes” were then asked if they now smoke daily, some days, or not at all (former smokers). Current daily and non-daily smokers were asked if they ever quit smoking for six months or longer and for how many years they quit. Former smokers were asked if they ever quit smoking for six months or longer before stopping completely and how many years total they quit during their previous quit attempt. Smoking cessation status was assigned based on three mutually exclusive categories: 1) current smoker and never quit for six months or longer; 2) current smoker and quit in past for six months or longer (ever tried to quit); and 3) no longer smokes (former smoker).
Tobacco use measures included age first started to smoke cigarettes regularly, number of years smoked cigarettes, and, on average, number of cigarettes per day. Lifetime pack-years were calculated based on age at smoking initiation, periods of quitting, and average lifetime cigarettes per day. Reproducibility of smoking variables was assessed in a sample of 56 individuals through repeated study visits conducted a median of 42 days apart. This analysis yielded a kappa of 0.93 for smoking status and intraclass correlation coefficients of 0.89 for age started smoking, 0.92 for current cigarettes per day, and 0.83 for lifetime average cigarettes per day.10 The kappa for ‘ever quit smoking for six months or longer’ was 0.81.
Exposure to smoking by others was measured by questions ascertaining whether the respondent lived with someone who smoked in the home before age 13 and after age 13, and number of current household members who smoke regularly in the home. Former smokers and current smokers with a previous quit attempt were asked the main reasons they quit: advice of physician; health reasons/self-initiated; pressure from others; and other reason. Because a large number of participants offered other reasons why they quit, these responses were coded and included in the analysis. Another question asked about various quit methods ever used, including: prescription gums, patches, medications; over-the-counter aids; and behavioral or group therapy.
Acculturation was measured with a modified ten-item version of the Short Acculturation Scale for Hispanics (SASH),35 comprising two subscales. The first subscale, with six items, reflects language preferences, e.g., language usually speaks at home, and with friends. The second four-item subscale reflects socializing practices and preferences, e.g., how many close friends are Hispanic/Latino, prefers social gatherings with Hispanics/Latinos. Each subscale employs five-point Likert-type responses. Higher scores represent greater acculturation to the dominant U.S. culture. Language subscale reliability in the full sample yielded Cronbach’s alpha of 0.92, and 0.80 for the English-language version and 0.85 for the Spanish-language version. The full sample alpha for the social subscale was 0.73, and 0.65 and 0.71 for the English and Spanish versions, respectively. Additional acculturation-related variables include nativity (born in the 50 U.S. states or District of Columbia vs. foreign-born, with Puerto Rican-born considered foreign-born in this analysis) and number of years living in the mainland United States. National background was assessed through the question: “Which of the following best describes your Hispanic/Latino heritage?” with possible responses including Dominican, Central American, Cuban, Mexican, Puerto Rican, South American, other, or more than one.
Statistical Analysis
The analyses for the present study were restricted to respondents with a lifetime history of smoking at least 100 cigarettes. All analyses employed sampling weights to account for unequal probabilities of selection into the original sample, and included adjustments for non-response, trimming of extreme values, and calibration to the 2010 U.S. Census population according to age, sex, and Hispanic/Latino distributions in the four study sites.33,34 Analyses were performed using SAS, version 9.3 (SAS Institute, Cary NC) and SUDAAN release 11.0.1 (RTI International, Research Triangle Park, NC).
The goal of the analysis was to describe factors associated with the three-category variable capturing smoking cessation attempts and success. Independent variables of interest included demographics (age, gender, marital status), socioeconomic status (income, education), smoking exposure (age at initiation, smoking intensity and presence of other smokers in the home), national background, and acculturation. Because national background was highly correlated with field site, we did not adjust for site. Because age at interview was strongly associated with smoking cessation, analyses were adjusted for age based on multinomial logistic regression models using PROC MULTILOG in SUDAAN software, with the three-level quit smoking status variable as the dependent variable and age as a continuous covariate. Conditional marginals were computed according to levels of each covariate and 95% confidence intervals were calculated.36 To evaluate whether characteristics differed across categories of smoking cessation, p-values corresponding to an omnibus test for differences between groups were computed. Mean values and corresponding standard errors for continuous variables, conditional on smoking cessation category, were similarly computed. Weighted least squares regressions using PROC REGRESS in SUDAAN software, with cessation status and age as independent variables, were used to estimate mean values. Interaction terms were added to explore differences in effects of nativity and acculturation by Hispanic/Latino national background group. Frequency distributions for reasons quit and cessation methods were computed without age adjustment and p-values for quit reasons were calculated based on an omnibus test comparing those who no longer smoked to those who currently smoked and reported a past quit attempt. All analyses were stratified by gender. All tests of significance were two-sided and based on a significance level of 5%, with no corrections made for multiple comparisons.
A series of gender-specific multivariable logistic regression models were constructed to identify predictors of sustained smoking cessation. Analyses were restricted to former smokers (sustained cessation) and current smokers reporting a past quit attempt of at least 6 months. The initial model included sociodemographic variables, national background, and tobacco use. Adjusted odds ratios and 95% confidence intervals were computed. Subsequently, acculturation and quit characteristic variables were added individually to separate models, each containing all of the above covariates. Because age was strongly associated with acculturation and cessation, an interaction term was then added to each model to assess effect modification by acculturation level and age (under age 40 versus 40+). Participants with missing data for any covariates were removed from all multivariable models (n=149, or 3% of 4,938). Stratified odds ratios for acculturation and corresponding 95% confidence intervals were computed.
RESULTS
A total of 6,398 participants (39% of the full sample) reported lifetime prevalence of at least 100 cigarettes; 94 individuals missing smoking or cessation data were excluded from the present analysis. Among those with a history of smoking, proportions of current smokers who never made a quit attempt, current smokers who tried to quit in the past, and former smokers were relatively equivalent by gender (Table 1). Sociodemographic patterns were similar for men and women. Older individuals were more likely to be former smokers. Individuals who were married or living with a partner were more likely to be former smokers than those not married. Unmarried individuals were more often current smokers who never tried to quit. Smoking cessation was moderately associated with higher educational achievement. Those with at least some college included the greatest percentage of former smokers and the fewest smokers who never tried to quit. The likelihood of being a former smoker increased with income while the proportion of smokers who never tried to quit decreased as income rose.
Table 1:
Sociodemographic and Tobacco Use Characteristics Associated with Smoking Cessation among Hispanics/Latinos with Lifetime Smoking of at Least 100 Cigarettes—Age-Adjusted (n=6398)a
| Women |
Men |
|||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Current smoker-Never tried to quit (n=644) | Current smoker -Ever tried to quit (n=841) | No longer smokes (n=1533) | Current smoker-Never tried to quit (n=816) | Current smoker -Ever tried to quit (n=864) | No longer smokes (n=1700) | |||||
| nb | % (95% CI)c | nb | % (95% CI)c | |||||||
| Overall | 3018 | 24.6 (22.4, 27.0) | 31.6 (28.8, 34.5) | 43.8 (40.8, 46.9) | 3380 | 27.4 (25.1, 29.7) | 27.6 (25.5, 29.9) | 45.0 (42.5, 47.5) | ||
| Age at baseline visit | *** | *** | ||||||||
| 18–29 | 307 | 28.1 (22.1, 35.0) | 45.1 (38.0, 52.4) | 26.8 (20.3, 34.5) | 446 | 34.4 (28.9, 40.3) | 40.3 (34.6, 46.3) | 25.3 (20.7, 30.6) | ||
| 30–39 | 319 | 20.5 (14.9, 27.5) | 41.3 (30.3, 53.3) | 38.2 (29.5, 47.7) | 469 | 27.2 (22.3, 32.8) | 33.5 (27.6, 39.9) | 39.3 (33.7, 45.2) | ||
| 40–49 | 819 | 25.3 (21.5, 29.5) | 32.6 (28.2, 37.3) | 42.1 (37.5, 47.0) | 852 | 27.6 (23.5, 32.1) | 27.2 (23.4, 31.3) | 45.3 (40.4, 50.2) | ||
| 50–59 | 1035 | 24.0 (20.7, 27.6) | 24.3 (21.3, 27.6) | 51.7 (47.7, 55.7) | 948 | 24.5 (20.4, 29.2) | 21.9 (18.1, 26.2) | 53.6 (48.4, 58.8) | ||
| 60–75 | 538 | 20.0 (15.3, 25.6) | 16.0 (11.5, 21.8) | 64.0 (57.3, 70.2) | 665 | 16.8 (13.2, 21.1) | 12.4 (9.3, 16.4) | 70.8 (65.6, 75.5) | ||
| Marital status | *** | *** | ||||||||
| Unmarried | 1773 | 29.7 (26.6, 32.9) | 32.0 (28.6, 35.5) | 38.3 (34.9, 41.8) | 1395 | 35.0 (31.4, 38.7) | 28.2 (24.9, 31.6) | 36.8 (33.1, 40.6) | ||
| Married/living with partner | 1238 | 17.8 (14.8, 21.1) | 31.2 (27.0, 35.8) | 51.0 (46.3, 55.7) | 1976 | 20.5 (17.9, 23.3) | 27.2 (24.3, 30.3) | 52.3 (48.9, 55.7) | ||
| Highest level education | ** | * | ||||||||
| Less than 9th grade | 611 | 31.8 (25.9, 38.4) | 24.7 (19.8, 30.3) | 43.6 (37.7, 49.6) | 810 | 29.7 (24.9, 34.9) | 23.9 (19.6, 28.8) | 46.5 (41.4, 51.6) | ||
| Some high school | 520 | 29.9 (24.1, 36.4) | 33.3 (27.0, 40.2) | 36.8 (30.3, 43.9) | 590 | 29.8 (24.9, 35.2) | 28.2 (22.7, 34.4) | 42.0 (36.0, 48.2) | ||
| Completed high school/equivalent | 710 | 22.5 (18.7, 26.8) | 34.6 (28.7, 41.0) | 42.9 (37.4, 48.7) | 919 | 28.8 (24.8, 33.2) | 31.3 (27.3, 35.7) | 39.9 (35.4, 44.5) | ||
| At least some college | 1172 | 20.7 (17.6, 24.1) | 31.7 (27.9, 35.8) | 47.6 (43.2, 52.1) | 1052 | 23.3 (19.5, 27.6) | 26.4 (22.8, 30.3) | 50.3 (46.1, 54.5) | ||
| Household income | ** | |||||||||
| < $10,000 | 608 | 30.4 (25.4, 35.8) | 29.8 (24.0, 36.2) | 39.9 (33.7, 46.4) | 459 | 34.8 (28.7, 41.4) | 33.1 (26.9, 40.0) | 32.1 (26.6, 38.2) | ||
| $10,001-$20,000 | 899 | 24.0 (20.1, 28.3) | 34.2 (29.0, 39.8) | 41.8 (36.6, 47.3) | 990 | 29.1 (24.9, 33.7) | 30.0 (25.8, 34.6) | 40.9 (36.2, 45.7) | ||
| $20,001-$30,000 | 484 | 24.1 (19.0, 30.0) | 28.7 (22.9, 35.4) | 47.2 (40.1, 54.4) | 623 | 20.8 (16.7, 25.6) | 27.7 (22.6, 33.4) | 51.5 (45.4, 57.7) | ||
| $30,001-$40,000 | 338 | 21.6 (15.7, 28.9) | 36.7 (27.8, 46.6) | 41.7 (33.6, 50.4) | 480 | 25.4 (20.2, 31.3) | 20.5 (16.4, 25.4) | 54.1 (47.5, 60.6) | ||
| > $40,000 | 372 | 16.7 (11.9, 23.1) | 30.1 (21.8, 39.8) | 53.2 (43.8, 62.4) | 609 | 19.3 (14.1, 25.8) | 28.0 (22.8, 33.9) | 52.7 (46.5, 58.8) | ||
| Years smoking/smoked, mean (SE) | 3018 | 25.7 (0.5) | 21.5 (0.4) | 14.4 (0.4) | *** | 3380 | 25.2 (0.3) | 22.0 (0.3) | 14.2 (0.3) | *** |
| Lifetime pack-years, mean (SE) | 2994 | 17.6 (0.9) | 11.5 (0.6) | 9.4 (0.5) | *** | 3334 | 19.6 (0.7) | 13.9 (0.7) | 11.5 (0.5) | *** |
| Smoking intensity | *** | *** | ||||||||
| Daily | 1058 | 54.1 (50.3, 58.0) | 45.9 (42.0, 49.7) | n/a | 1105 | 59.7 (56.0, 63.3) | 40.3 (36.7, 44.0) | n/a | ||
| Intermittent | 427 | 22.1 (16.5, 28.9) | 77.9 (71.1, 83.5) | n/a | 575 | 29.8 (24.5, 35.7) | 70.2 (64.3, 75.5) | n/a | ||
| Former | 1533 | n/a | n/a | 100.0 | 1700 | n/a | n/a | 100.0 | ||
| Cigarettes per day (quartiles) | *** | *** | ||||||||
| ≤ 1 | 280 | 13.8 (8.1, 22.4) | 30.3 (22.2, 39.8) | 56.0 (47.0, 64.6) | 250 | 19.1 (12.7, 27.7) | 29.0 (21.3, 38.0) | 52.0 (43.3, 60.6) | ||
| 2–20 | 2497 | 25.7 (23.1, 28.5) | 33.0 (29.9, 36.3) | 41.3 (38.0, 44.6) | 2732 | 28.1 (25.6, 30.7) | 28.9 (26.5, 31.4) | 43.0 (40.3, 45.8) | ||
| > 20 | 236 | 25.2 (17.9, 34.3) | 15.8 (10.2, 23.7) | 59.0 (50.0, 67.4) | 385 | 27.4 (21.6, 34.1) | 16.0 (11.6, 21.5) | 56.6 (49.0, 63.9) | ||
| Age began smoking | ** | *** | ||||||||
| < 18 | 1447 | 28.7 (25.3, 32.3) | 30.4 (25.9, 35.4) | 40.9 (36.4, 45.6) | 2105 | 28.0 (25.3, 30.8) | 26.7 (24.0, 29.6) | 45.4 (42.1, 48.7) | ||
| 18–24 | 1098 | 19.7 (16.6, 23.3) | 32.4 (27.9, 37.4) | 47.8 (43.4, 52.3) | 1005 | 24.5 (20.6, 28.9) | 27.6 (24.0, 31.6) | 47.9 (43.5, 52.2) | ||
| 25 or older | 434 | 23.8 (17.7, 31.1) | 35.8 (28.5, 43.8) | 40.5 (34.1, 47.2) | 220 | 36.6 (27.0, 47.3) | 35.8 (27.3, 45.2) | 27.6 (21.0, 35.5) | ||
| Smoker in household before age 13 | ** | *** | ||||||||
| No | 1085 | 18.9 (15.8, 22.4) | 31.0 (26.9, 35.4) | 50.2 (45.2, 55.1) | 1322 | 22.7 (19.6, 26.1) | 25.7 (22.3, 29.5) | 51.6 (47.9, 55.2) | ||
| Yes | 1919 | 27.7 (24.6, 31.1) | 31.9 (28.3, 35.7) | 40.4 (36.6, 44.3) | 2045 | 30.4 (27.6, 33.4) | 28.9 (26.3, 31.6) | 40.7 (37.6, 43.9) | ||
| Smoker in household since age 13 | *** | *** | ||||||||
| None | 867 | 14.8 (11.7, 18.5) | 24.5 (20.2, 29.4) | 60.7 (55.4, 65.8) | 1154 | 21.0 (17.9, 24.6) | 22.0 (18.5, 25.9) | 57.0 (52.6, 61.3) | ||
| Yes, but not now | 1248 | 21.8 (18.6, 25.5) | 28.8 (25.0, 33.0) | 49.3 (44.6, 54.1) | 1427 | 25.2 (22.0, 28.7) | 27.1 (23.8, 30.8) | 47.6 (43.5, 51.9) | ||
| Yes, including currently | 898 | 36.4 (31.5, 41.6) | 40.8 (34.9, 47.0) | 22.8 (19.1, 26.8) | 791 | 39.7 (35.1, 44.4) | 36.3 (31.8, 41.1) | (20.3, 28.1) | ||
Based on HCHS/SOL study, Chicago, Miami, Bronx, San Diego, 2008-2011
Subgroup n’s may not add up to column totals due to missing data
All values are age-adjusted row percents unless otherwise stated
P<0.05
P<0.01
P<0.001
P-values based on omnibus test for any differences between groups, or test for linear trend (income only)
A higher likelihood of successful quitting was found among very light smokers (≤1 cigarettes/day) and among the heaviest smokers (>20 cigarettes/day) compared to those who smoked up to a pack a day (Table 1). Men who started smoking after age 25 were much less likely to have quit than men who initiated when younger. Women and men who were daily smokers were much less likely to have tried to quit in the past compared to non-daily (intermittent) smokers. Women and men who either currently or in the past lived in households where no one else smoked were more likely to be former smokers.
Smoking cessation and quit attempts were strongly related to national background and acculturation-related factors (Table 2). Men and women exhibited somewhat different patterns by national background in the likelihood of being a former smoker; cessation by women was highest among Mexicans and, for men, among South Americans. For both men and women, the highest proportions of smokers who never tried to quit were those of Puerto Rican and Cuban background. Non-U.S. born individuals were more likely to be former smokers compared to U.S. born. The association of nativity with quitting was consistent in subgroup analyses of each national background group (data not shown). Men and women with lower language-related acculturation scores were more likely to be former smokers, with little variation in this association by national background (data not shown).
Table 2:
Sociocultural Factors Associated with Smoking Cessation among Hispanics/Latinos with Lifetime Smoking of at least 100 cigarettes – Age-Adjusted (n=6398)a
| Women |
Men |
|||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Current smoker -never tried to quit (n=644) | Current smoker - ever tried to quit (n=841) | No longer smokes (n=1533) | Current smoker –never tried to quit (n=816) | Current smoker -ever tried to quit (n=864) | No longer smokes (n=1700) | |||||
| nb | % (95% CI)c | nb | % (95% CI)c | |||||||
| Hispanic/Latino background | *** | *** | ||||||||
| Dominican | 216 | 24.5 (17.0, 33.9) | 31.5 (19.3, 46.8) | 44.0 (33.8, 54.8) | 146 | 28.3 (17.9, 41.8) | 18.3 (11.6, 27.7) | 53.3 (40.1, 66.1) | ||
| Central American | 222 | 18.8 (12.6, 27.1) | 24.5 (17.8, 32.7) | 56.7 (48.7, 64.4) | 309 | 28.9 (22.4, 36.4) | 21.2 (16.5, 26.9) | 49.8 (42.5, 57.2) | ||
| Cuban | 536 | 33.9 (28.7, 39.5) | 32.4 (28.3, 36.9) | 33.7 (28.8, 38.9) | 637 | 35.8 (31.8, 40.1) | 29.5 (25.2, 34.2) | 34.7 (30.1, 39.7) | ||
| Mexican | 1017 | 10.4 (7.9, 13.5) | 30.7 (25.6, 36.2) | 58.9 (53.2, 64.4) | 1293 | 19.7 (16.4, 23.4) | 27.5 (23.5, 31.9) | 52.8 (48.4, 57.2) | ||
| Puerto Rican | 765 | 37.1 (31.9, 42.7) | 31.6 (26.9, 36.6) | 31.3 (26.4, 36.7) | 660 | 35.3 (30.4, 40.5) | 32.9 (27.9, 38.3) | 31.8 (26.5, 37.7) | ||
| South American | 156 | 20.8 (14.1, 29.4) | 29.9 (21.8, 39.5) | 49.3 (40.0, 58.7) | 213 | 16.4 (10.6, 24.5) | 14.1 (8.7, 21.9) | 69.5 (60.2, 77.5) | ||
| Other/more than one | 100 | 18.2 (10.6, 29.6) | 41.8 (26.4, 59.1) | 39.9 (25.9, 55.8) | 116 | 16.7 (10.0, 26.5) | 27.9 (18.8, 39.4) | 55.4 (42.9, 67.1) | ||
| Nativity | *** | * | ||||||||
| Foreign-born | 2351 | 21.5 (19.1, 24.1) | 30.7 (27.6, 34.0) | 47.8 (44.2, 51.4) | 2765 | 25.4 (23.0, 28.0) | 27.6 (25.2, 30.2) | 47.0 (44.1, 49.8) | ||
| Born within U.S. 50 states | 663 | 33.3 (27.6, 39.5) | 34.0 (28.5, 39.9) | 32.7 (27.4, 38.5) | 611 | 33.6 (28.1, 39.7) | 28.0 (23.4, 33.1) | 38.4 (32.9, 44.2) | ||
| Years in U.S. mainlandd, mean (SE) | 2341 | 19.4 (1.0) | 19.0 (0.9) | 18.3 (0.6) | 2759 | 18.3 (0.8) | 19.1 (0.6) | 17.3 (0.6) | * | |
| Acculturation -language subscale, mean (SE) | 3014 | 2.27 (0.06) | 2.15 (0.07) | 1.99 (0.05) | *** | 3373 | 2.11 (0.07) | 2.11 (0.06) | 1.94 (0.04) | ** |
| Acculturation -social subscale, mean (SE) | 3014 | 2.22 (0.03) | 2.27 (0.04) | 2.21 (0.03) | 3372 | 2.21 (0.03) | 2.27 (0.03) | 2.23 (0.02) | ||
Based on HCHS/SOL study, Chicago, Miami, Bronx, San Diego, 2008-2011
Subgroup n’s may not add up to column totals due to missing data
All values are age-adjusted row percents unless otherwise stated
Among foreign-born
P<0.05
P<0.01
P<0.001
P-values based on omnibus test for any differences between groups
Table 3 presents reasons for quitting smoking and quit methods ever used. Approximately three-quarters of male and female former smokers quit on their own for self-motivated reasons, e.g., for better health, they no longer enjoyed smoking, or they felt like quitting. Among unsuccessful quitters, relatively fewer women than men were motivated by such reasons. Almost one-quarter of women who had a prior period of quitting but did not remain abstinent mentioned pregnancy as the reason for a previous quit attempt. While percentages were very low overall, relatively more women than men said they quit for the sake of family members. Both men and women were largely able to quit on their own without assistance. In general, there were few differences in quitting methods between former smokers and unsuccessful quitters. Only 2.0% of former smokers and 3.5% of current smokers with a previous quit attempt tried more than one quit method (data not shown). There was some variation by national background in whether any quitting method was used, with Puerto Rican men and women the most likely to have used assistance in quitting.
Table 3:
Reasons Quit Smoking and Methods Used among Current Smokers Who Ever Quit for 6 Months or Longer and Former Smokersa
| Overall |
Women |
Men |
||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Current smoker – ever tried to quit (n=1705) | No longer smokes (n=3233) | Current smoker –ever tried to quit (n=841) | No longer smokes (n=1533) | Current smoker – ever tried to quit (n=864) | No longer smokes (n=1700) | |||||||
| nb | column %c | nb | column %c | nb | column %c | |||||||
| Reason quit smoking, % | *** | *** | ** | |||||||||
| Advice of physician | 282 | 3.9 | 5.0 | 135 | 4.6 | 4.3 | 147 | 3.3 | 5.5 | |||
| Health reasons, self-initiated | 3662 | 69.2 | 77.8 | 1659 | 56.4 | 75.0 | 2003 | 78.7 | 79.5 | |||
| Pressure from others | 459 | 10.1 | 9.2 | 208 | 7.9 | 8.6 | 251 | 11.8 | 9.6 | |||
| Religion-related | 87 | 0.6 | 2.0 | 49 | 0.3 | 2.4 | 38 | 0.8 | 1.8 | |||
| For sake of family/others | 71 | 1.5 | 1.8 | 35 | 3.1 | 2.6 | 36 | 0.3 | 1.3 | |||
| Pregnancy-related | 214 | 10.3 | 1.4 | 211 | 23.6 | 3.5 | 3 | 0.3 | 0.1 | |||
| Cost/financial burden | 52 | 0.8 | 1.0 | 25 | 0.6 | 1.4 | 27 | 1.0 | 0.8 | |||
| Death of family member/friend | 10 | 0.3 | 0.1 | 6 | 0.7 | 0.2 | 4 | 0.1 | 0.1 | |||
| Illness of family member/friend | 14 | 0.3 | 0.3 | 11 | 0.8 | 0.4 | 3 | 0.0 | 0.2 | |||
| Institutionalized (jail/hospital/other) | 27 | 1.7 | 0.0 | 4 | 0.5 | 0.0 | 23 | 2.6 | 0.1 | |||
| Other/refused | 43 | 1.3 | 1.3 | 23 | 1.5 | 1.7 | 20 | 1.1 | 1.0 | |||
| Quit methods ever used, % d | ||||||||||||
| None | 4414 | 86.7 | 92.6 | *** | 2083 | 84.2 | 92.0 | *** | 2331 | 88.7 | 93.0 | ** |
| Prescription | 298 | 7.7 | 4.0 | *** | 171 | 8.6 | 5.0 | * | 127 | 7.0 | 3.3 | ** |
| Over the counter aid | 304 | 7.6 | 4.5 | *** | 169 | 9.8 | 4.1 | *** | 135 | 6.0 | 4.7 | |
| Behavioral/group therapy | 96 | 2.2 | 1.6 | 53 | 2.4 | 1.7 | 43 | 2.0 | 1.5 | |||
| Use of any quit method, by Hispanic/Latino background, %e | n/a | n/a | n/a | |||||||||
| Dominican | 285 | 16.9 | 10.5 | 170 | 16.1 | 13.1 | 115 | 18.8 | 8.0 | |||
| Central American | 426 | 8.9 | 6.9 | 194 | 13.1 | 13.5 | 232 | 6.6 | 2.4 | |||
| Cuban | 803 | 8.2 | 5.9 | 369 | 6.7 | 5.3 | 434 | 9.3 | 6.3 | |||
| Mexican | 1970 | 7.4 | 3.0 | 903 | 11.6 | 3.7 | 1067 | 5.0 | 2.7 | |||
| Puerto Rican | 970 | 27.8 | 19.5 | 526 | 30.7 | 18.9 | 444 | 25.4 | 20.1 | |||
| South American | 307 | 9.7 | 3.6 | 130 | 10.3 | 1.7 | 177 | 8.9 | 4.6 | |||
| Other/more than one | 162 | 14.5 | 12.6 | 76 | 16.3 | 5.2 | 86 | 12.6 | 16.0 | |||
Based on HCHS/SOL study, Chicago, Miami, Bronx, San Diego, 2008-2011
Subgroup n’s may not add up to column totals due to missing data
All values are column percents
Categories are not mutually-exclusive
P-values not computed for comparisons within Hispanic/Latino background subgroups due to wide variations in group sample sizes; overall, Hispanic/Latino background was a significant predictor of using quit aids and/or therapy in both women (p<0.0001) and men (p<0.0001)
P<0.05
P<0.01
P<0.001
P-values based on omnibus test for any differences between groups
Predictors of sustained smoking cessation were examined in gender-specific multivariable logistic regression analyses based on former smokers and current smokers who reported ever quitting for at least six months (Table 4). Adjusting for all other variables, the following factors were associated with increased odds of being a former smoker (sustained cessation), compared to current smokers with a previous quit attempt: older age, especially 50 years and above among men and women; married or living with a partner for both genders; heavier smoking (over a pack a day) by men and women; and, among women, quitting for self-motivated reasons. The odds of sustained cessation were reduced among men with lower incomes and men who began smoking after age 24; these characteristics were not associated with cessation among women. Unlike the bivariate findings, education and marital status were not associated with cessation. Both men and women who currently lived in a household with a smoker had lower odds of sustaining cessation. Men and women who used prescription or over the counter aids, and/or behavioral/group therapy to assist in cessation also had lower odds of sustaining cessation than those who did not use any assistance.
Table 4:
| Women (n=2,301) |
Men (n=2,485) |
|||
|---|---|---|---|---|
| OR | 95% CI | OR | 95% CI | |
| Model A (all variables mutually adjusted) | ||||
| Age at baseline visit | ||||
| 18–29 | 1.00 | (ref) | 1.00 | (ref) |
| 30–39 | 1.68 | (0.95, 2.96) | 1.59 | (1.01, 2.50) |
| 40–49 | 2.09 | (1.25, 3.48) | 2.40 | (1.57, 3.68) |
| 50–59 | 3.66 | (2.24, 5.95) | 3.30 | (2.04, 5.35) |
| 60–75 | 7.57 | (4.15, 13.80) | 10.13 | (6.15, 16.69) |
| Married/living with partner (ref=not) | 1.65 | (1.27, 2.14) | 1.34 | (1.00, 1.79) |
| Highest level education | ||||
| Less than 9th grade | 1.00 | (ref) | 1.00 | (ref) |
| Some high school | 0.74 | (0.47, 1.15) | 0.87 | (0.57, 1.35) |
| Completed high school/equivalent | 0.76 | (0.51, 1.15) | 0.68 | (0.46, 0.99) |
| At least some college | 0.87 | (0.58, 1.31) | 1.05 | (0.71, 1.56) |
| Annual household income | ||||
| Less than $30,000 | 1.00 | (ref) | 1.00 | (ref) |
| $30,000 or more | 0.93 | (0.68, 1.27) | 1.50 | (1.09, 2.06) |
| Missing income | 0.97 | (0.50, 1.89) | 0.67 | (0.36, 1.23) |
| Hispanic/Latino background | ||||
| Mexican | 1.00 | (ref) | 1.00 | (ref) |
| Dominican | 0.75 | (0.40, 1.42) | 2.13 | (1.07, 4.25) |
| Central American | 1.19 | (0.68, 2.11) | 1.30 | (0.80, 2.12) |
| Cuban | 0.57 | (0.41, 0.80) | 0.73 | (0.50, 1.07) |
| Puerto Rican | 0.50 | (0.33, 0.75) | 0.65 | (0.42, 1.01) |
| South American | 0.79 | (0.43, 1.44) | 3.53 | (1.88, 6.64) |
| Other/more than 1 | 0.64 | (0.29, 1.40) | 1.23 | (0.60, 2.50) |
| Cigarettes per day | ||||
| ≤ 1 | 1.00 | (ref) | 1.00 | (ref) |
| 2–20 | 1.06 | (0.66, 1.70) | 1.09 | (0.62, 1.90) |
| > 20 | 4.62 | (2.17, 9.86) | 3.42 | (1.69, 6.95) |
| Began smoking age 25 or older (ref: < 25) | 0.77 | (0.52, 1.15) | 0.38 | (0.22, 0.64) |
| Smoker in household before age 13 (yes vs. no) | 1.11 | (0.80, 1.55) | 0.85 | (0.62, 1.17) |
| Smoker in household since age 13 | ||||
| None | 1.00 | (ref) | 1.00 | (ref) |
| Yes, but not now | 0.69 | (0.46, 1.02) | 0.82 | (0.56, 1.20) |
| Yes, including currently | 0.18 | (0.11, 0.27) | 0.26 | (0.18, 0.38) |
| Model B (all variables in model A + each variable below added independently) | ||||
| Any quit method used (ref=no quit method used) | 0.36 | (0.25, 0.53) | 0.44 | (0.29, 0.66) |
| Self-initiated or health reasons (ref=all other) | 0.65 | (0.54, 0.79) | 0.85 | (0.69, 1.05) |
| Model C (Model A variables + acculturation variables added independently + age*acculturation interaction) | ||||
| Nativity (U.S. mainland vs. foreign-born) | ||||
| Age 18–39 | 0.65 | (0.40, 1.08) | 0.85 | (0.51, 1.42) |
| Age ≥ 40 | 0.93 | (0.55, 1.60) | 0.95 | (0.59, 1.52) |
| SASH language subscale (1-point increase) | ||||
| Age 18–39 | 0.84 | (0.65, 1.09) | 0.87 | (0.70, 1.09) |
| Age ≥ 40 | 1.02 | (0.86, 1.21) | 0.91 | (0.76, 1.09) |
| SASH social subscale (1-point increase) | * | |||
| Age 18–39 | 0.52 | (0.33, 0.82) | 0.87 | (0.57, 1.31) |
| Age ≥ 40 | 1.04 | (0.82, 1.33) | 0.92 | (0.70, 1.20) |
Based on HCHS/SOL study, Chicago, Miami, Bronx, San Diego, 2008-2011
Odds ratios (OR) represent the odds of being a former smoker compared to current smokers who ever quit for 6 months or longer, after adjustment for other variables in the model.
Interaction with age significant, p=0.0045. All other age interactions were not significant at p<0.05.
The multivariable analysis exhibited different patterns for men and women by national background and acculturation, and these persisted after adjusting for differences in socioeconomic status and smoking exposures (Table 4). Among men, Dominicans and South Americans were most likely to successfully quit, while among women, no group had a markedly higher likelihood of quitting. Puerto Rican and Cuban men and women were the least likely to successfully quit. Place of birth had no independent association with quitting. However, the association between acculturation and quitting was characterized by gender differences and an age interaction; women under age 40 scoring higher on the social acculturation scale had reduced odds of sustaining cessation compared to older less acculturated women.
DISCUSSION
Similar to findings from several other U.S. national surveys,15,30 acculturation was related to smoking cessation, particularly for women, in this national sample of Hispanics/Latinos. The likelihood of being a former smoker was significantly lower for younger, more socially acculturated women. This finding is consistent with HCHS/SOL data reported elsewhere regarding risk of smoking initiation during adolescence,37 and with studies showing declines in health-promoting behaviors among U.S. Hispanics/Latinos as acculturation increases.20,21
Thus, acculturation influences not only initiation of smoking for Hispanic/Latina women,19,20 but also cessation. Possibly, less acculturated Hispanic/Latina women find it easier to quit in light of traditional gender norms that discourage smoking by women.38,39 Greater acculturation may lead to decreased cessation as a reflection of the generally higher levels of smoking found among non-Hispanics/Latinos and women in the U.S. Continued smoking may reflect a coping response to stress associated with the acculturation process.40,41 However, as non-smoking norms become increasingly prevalent in the United States, smoking may also decrease among more acculturated Hispanics/Latinos as they adopt these changing attitudes and behaviors. Future research should focus on examining the underlying dynamics of the complex relationship between acculturation and health behaviors. In particular, a more nuanced understanding of acculturation as an influence on health requires attention to interactions with structural constraints, social contexts, and lived experiences.40–42
Although national surveys indicate lower overall population prevalence of former smoking among Hispanic/Latina women compared to men,11,15 this study found approximately equal proportions of former smokers by gender and similar patterns of tobacco use among men and women with a history of smoking. This finding is similar to an earlier analysis of HCHS/SOL data, which indicated that after adjustment for age, income, education, health insurance, and lifetime cigarette use, the likelihood of cessation was not associated with gender.10In general, men and women exhibited similar patterns in the relationship of sociodemographic characteristics to smoking cessation. Differences in cessation by national background were more pronounced among men than women.
There are several noteworthy limitations to the present analysis. The HCHS/SOL study is limited to Hispanics/Latinos living in the four field sites, and results cannot be generalized to other locations nor are they representative of the overall U.S. Hispanic/Latino population. Measures of smoking behaviors are based on self-report and may be subject to bias in recall and social desirability. The measure of acculturation was limited to a single scale and, therefore, does not capture the full multidimensional and dynamic aspects of the construct. All information is cross-sectional; measures of education, income, marital status, and acculturation were obtained at the time of interview and could not be temporally linked to episodes of quitting. Measures of insurance and access to healthcare were excluded because these also reflected status only at time of interview. The analysis did not examine whether cessation was associated with the presence of a chronic disease, a possible motivating factor. Variations across field sites, and hence national background, may be influenced by differences in state and local tobacco taxes and smoking regulations.43 It is worth noting that all four states represented in the study have Spanish-language smoking quit lines. While the large sample size made it possible to examine a large number of variables, as a result, some findings that achieved statistical significance had relatively modest effect sizes and may have been due to chance.
CONCLUSIONS
The findings have a number of implications for smoking cessation services. Clinicians, health educators, and public health professionals need to recognize the considerable heterogeneity in smoking behaviors among Hispanics/Latinos 44,45 and avoid generalizations based on the overall low prevalence of smoking among Hispanics/Latinos, particularly among women. Cuban and Puerto Rican smokers of both genders may require particular assistance in quitting smoking. Cities with high concentrations of Hispanics/Latinos from these national backgrounds should develop public health efforts tailored to them. The relatively high rate of apparent relapse after pregnancy underscores the importance of developing interventions focusing on women during the perinatal period.46–50 The significance of family as a motivation for quitting also should be explored further when developing cessation programs for Hispanic/Latina women. Cessation efforts should target non-daily and lighter smokers, a group that is more prevalent among Hispanics/Latinos, and often overlooked.6,51–53
Similar to national survey findings,4 there was relatively low use of tobacco cessation aids in this sample of Hispanics/Latinos. This may in part be due to income-related factors. Previous analysis of HCHS/SOL indicated that after adjustment for health insurance and other factors, use of over-the-counter cessation aids by former smokers was associated with higher income.10 The present analysis clearly indicates that many Hispanics/Latinos, particularly women, who successfully stop smoking are self-motivated to quit and can do so on their own. There is promising evidence that U.S. Hispanics/Latinos respond well to mass media campaigns promoting quitting.54 Clinical cessation counseling and public health efforts can build on these foundations to support Hispanic/Latino smokers in their attempts to quit smoking and remain abstinent.
Acknowledgements
The Hispanic Community Health Study/Study of Latinos was carried out as a collaborative study supported by contracts from the National Heart, Lung, and Blood Institute (NHLBI) to the University of North Carolina (N01-HC65233), University of Miami (N01-HC65234), Albert Einstein College of Medicine (N01-HC65235), Northwestern University (N01-HC65236), and San Diego State University (N01-HC65237). The following Institutes/Centers/Offices contribute to the HCHS/SOL through a transfer of funds to the NHLBI: National Institute on Minority Health and Health Disparities, National Institute on Deafness and Other Communication Disorders, National Institute of Dental, Craniofacial Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Neurological Disorders and Stroke, NIH Institution-Office of Dietary Supplements.
The authors thank the staff and participants of the Hispanic Community Health Study/Study of Latinos for their important contributions to the study.
The HCHS/SOL investigators: Larissa Avilás-Santa, Paul Sorlie, and Lorraine Silsbee, NHLBI; Robert Kaplan and Sylvia Wassertheil-Smoller, Albert Einstein College of Medicine; Martha L. Daviglus, Aida L. Giachello, and Kiang Liu, Northwestern University Feinberg School of Medicine and University of Illinois at Chicago; Neil Schneiderman, David Lee, and Leopoldo Raij, University of Miami; Greg Talavera, John Elder, Matthew Allison, and Michael Criqui, San Diego State University and University of California, San Diego; Jianwen Cai, Gerardo Heiss, Lisa LaVange, and Marston Youngblood, University of North Carolina, Chapel Hill; Bharat Thyagarajan and John H. Eckfeldt, University of Minnesota, Minneapolis; Karen J. Cruickshanks, University of Wisconsin; Elsayed Soliman, Wake Forest University; Hector Gonzalez, Thomas Mosley, University of Mississippi Medical Center; John H. Himes, University of Minnesota; R. Graham Barr and Paul Enright, Columbia University; and Susan Redline, Case Western Reserve University.
Footnotes
Conflict of Interest Statement
The authors declare that there are not conflicts of interest.
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