Overview: Tobacco-Related Disparities Among Hispanics/Latinos TM 2005 National Conference on Tobacco...

Overview: Tobacco-Related Disparities Among Hispanics/Latinos

TM

2005 National Conference on Tobacco or HealthMay 4, 2005

Centers for Disease Control and PreventionOffice on Smoking and Health

Introduction



Nisha Gupta, MPHOffice on Smoking and Health

TM

Topics

Program Development and Capacity BuildingDebra Torres

Smoking among Hispanics/LatinosRalph Caraballo

Border Region Opportunities and OSH Initiatives Nisha Gupta

Hispanic/Latino Adult Tobacco SurveyRalph Caraballo

Program Development& Capacity Building

Debra S. Torres, MPHOffice on Smoking and Health


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.

http://health.dailynewscentral.net/images/stories/158x158/smoking.jpg

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 outletsie., 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, MPHOffice on Smoking and Health


TM

Smoking among Hispanics/Latinos

TM


Ralph Caraballo, PhD, MPHOffice on Smoking and Health

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

Source: Hispanics: A People in Motion; The Pew Hispanic Center, January 2005

5%

7%

3%

4%

10%

8%

Mexican

South American

Central American

Dominican

Cuban

Puerto Rican

All Other Hispanic

63%

25.1

5.33.2 2.4 1.4

0

5

10

15

20

25

30

Mexico Central andSouth

America

Puerto Rico OtherHispanic

Cuba

Mil

lio

ns

Source: Current Population Survey, March 2002, PGP-5

Hispanics/Latinos in U.S. by Ancestry: 2002

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

Population Growth:U.S. Population by Race/Ethnicity

AAPI AIANBlackWhite Hispanic

12.6%

69.4%

2000

24.4%

50.1%

2050

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

Hispanic/Latino Population—United States

47.7

35.6

22.4

59.7

73.1

87.6

102.6

0

10

20

30

40

50

60

70

80

90

100

110

1990 2000 2010 2020 2030 2040 2050

Po

pu

lati

on

in m

illio

ns

High Percent of Hispanics Lower Percent of Hispanics

10 U.S. States Where 80% of Hispanics Reside (Year 2000)

CA

NV

AZ

CO

NM

TX

IL

NY

FL

NJ

Census 2000: Top 10 States by Hispanic Percent Change Since 1990

155

166

173

208

211

278

300

337

394

217

Percent change

Nebraska

N. Carolina

Arkansas

Georgia

Tennessee

Nevada

S. Carolina

Alabama

Kentucky

Minnesota

47.0

25.028.0

0

10

20

30

40

50

Mil

lio

ns

Source: Pew Hispanic Center/Kaiser Family Foundation National Survey of Latinos, December 2002

Language Use Among U.S. Hispanic/Latino Adults, 2002

Spanish Dominant Bilingual English Dominant

55.4

44.6

0

10

20

30

40

50

60

70

Pe

rce

nt

Source: Pew Hispanic Center tabulations from the Annual Social and Economic Supplement, Current Population Survey, March 2004

Native/Foreign Born U.S. Hispanics/Latinos: 2004

Native Born Foreign Born

Legal/Undocumented Hispanics/Latinos: Living in U.S.: 2004

31.6

8.4

0

10

20

30

40

50

Mil

lio

ns

Source: Pew Hispanic Center estimates based on March 2004 Current Population Survey (Passel 2005). Includes an allowance for persons omitted from the CPS.

Legal Undocumented

No Health Insurance by Race/Ethnicity and Place of Birth (Native vs. Foreign), 2004

20.918.6

13.810.9

31.1

21.516.1

50.2

0

10

20

30

40

50

60

70

Pe

rce

nt

Source: U.S. Census Bureau, Current Population Survey, 2004, Annual Social and Economic Supplements

Hispanic Black Asian White

Native Foreign

(Population 25 years and over)32.1

22.3

19.2

15.4

4.0

0

5

10

15

20

25

30

35

Mexican Central andSouth

American

Cuban Puerto Rican Non-HispanicWhite

Pe

rce

nt

Source: Current Population Survey, March 2002, PGP-5

Percent with Less Than 9th Grade Completed by Hispanic/Latino Origin: 2002

Smoking among Youth

Targeted Marketing and Promotion

Magazines

Point of purchase advertising

Current Smoking among Latino Adolescents (12-17 years), by Gender, 1999-2001

Source: National Survey on Drug Use and Health, 1999-2001

Boy Girl

14.3

11.4 11.29.9

10.6 10.49.3

10.0

0

2

4

6

8

10

12

14

16

18

20

Pe

rce

nt

Cuban Mexican

Puerto Rican

Central and South American

15.4

4.8

10.111.3

1.0

6.1

11.4 10.6 11

0

10

20

30

Boy Girl Overall

Pe

rce

nt

Source: Encuesta Nacional de Adicciones, México, 2002, and National Survey on Drug Use and Health, 1999-2001

Current Smoking among Youth 12-17 Years:Mexico (urban), Mexico (rural), and U.S. Mexican/Mexican-American

Urban Rural Mexican/Mexican Americans

13.0

20.7

0

10

20

30

Overall

Pe

rce

nt

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 Rural

Smoking among Adults

Smoking* Trends: Adults, 1983-2002

* Smoking on 1 or more of the previous 30 days.Source: National Health Interview Surveys, 1983-2002, selected years, aggregate data

American Indian/Alaska Native

African American

Asian/Pacific Islander

White

HP 2010Goal(12%)

Hispanic/Latino

0

10

20

30

40

50

1983-1985

1987-1988

1990-1991

1992-1993

1994-1995

1997-1998

1999-2000

2001-2002

Years

Pe

rce

nt

30.4

23.122.8 21.3 19.2

0

10

20

30

40

50

60

Pe

rce

nt

Current Smoking: Hispanic/Latino Adults, by Specific Population, 1999-2001


Puerto Rican Mexican Central orSouth American

Cuban Overall

HP 2010Goal(12%)

34.2

29.8

26.3

21.1

15.616.9 17.5

27.3

0

10

20

30

40

50

Pe

rce

nt

Current Smoking Among Adults, by Specific Population Gender: 1999-2001


PuertoRican

Mexican

Central and South

American

Cuban

Men Women

45.3

18.4

30.232.3

4.2

16.6

29.8

15.6

22.8

0

10

20

30

40

50

60

Men Women Overall

Pe

rce

nt

Source: Encuesta Nacional de Adicciones, México, 2002, and National Survey on Drug Use and Health, 2002

Current Smoking among Adults:Mexico (urban), Mexico (rural), and U.S. Mexican/Mexican-American

Urban Rural Mexican/Mexican Americans

n Percent 95% C.I.Men

English 265 25 19.3 - 29.7

Spanish 355 20 16.1 - 24.5

Women

English 371 20 16.1 - 24.3

Spanish 300 3 0.8 - 4.5

Adult Smoking Prevalence Among Hispanics, by Gender And Survey Language, Oregon, 2000-01

Projection*: Adult Smokers (in millions) by Race/Ethnicity and Year

Population 2000 2025 2050Am. Indian <1.0 <1.0 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

White 36.8 40.3 41.1

*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

Source: National Health and Nutrition Examination Survey, 1999-2000

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

Percentage of Children (nonsmokers) Exposed to Secondhand Smoke, by Age and Race/Ethnicity—United States, 1999-2000


76.5

86.7

66.562.6

54.747.5

0

10

20

30

40

50

60

70

80

90

100

3 to 4 years 5 to 11 years

Pe

rce

nta

ge

African American White Mexican American

HP 2010 Goal (45%)

Percentage of Nonsmokers Aged 12 – 19 Years Exposed to Secondhand Smoke, by Race/Ethnicity—United States, 1999-2000


80.9

65

50.9

0

10

20

30

40

50

60

70

80

90

100

Pe

rce

nta

ge

HP 2010 Goal (45%)


Percentage of Adult Nonsmokers Exposed to Secondhand Smoke, by Race/Ethnicity and Age—United States, 1999-2000


68.8 65.959.3

47.6 47.3

39.545.5

38.6

29.7

0

10

20

30

40

50

60

70

80

90

100

20 - 34 35 - 64 65+ years

Pe

rce

nta

ge

HP 2010 Goal (45%)


54.7

38.6

29.7

47.550.9

45.5

0

10

20

30

40

50

60

Pe

rce

nt

Percentage of Mexicans/Mexican Americans (nonsmokers) Exposed to Secondhand Smoke, by Age—United States, 1999-2000


3 – 4 5 – 11 12 – 19 20 – 34 35 – 64

HP 2010 Goal(45%)

65+

AGE

Smoking During Pregnancy

Percent of Mothers Who Smoked During Pregnancy by Race/Ethnicity of Mother—United States, 1999

Source: National Vital Statistics Report, Vol. 49, No. 7, August 28, 2001Note: California and South Dakota did not report in 1999

AmericanIndian/

Alaska Native

White Hawaiian PuertoRican

Japanese Cuban Filipino Mexican ChineseBlack Central/South

American

20.2

15.914.7

10.59.4

4.53.3 3.3 2.6

1.40.5

0

5

10

15

20

25

Pe

rce

nt

TM



Smoking among Hispanics/Latinos

Border Region Opportunities and OSH Initiatives

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


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


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


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 todrink and drive than those born inother countries but living in the U.S

Abstention reported greater amongwomen 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, 2003Gilbert, J. Alcohol consumption patterns in immigrant and later generation Mexican American women. Hispanic Journal of Behavioral Sciences 9 (3): 299-313, 1987

http://www.thebeerstore.ca/ultimate/beer-types.html

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

TM



Hispanic LatinoAdult Tobacco Survey



TM

Topics

Background of Hispanic/LatinoAdult 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

Cigarette Smoking

Smoking Cessation


Risk Perception and Social Influences

Demographics

CORE

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?


Demographics– With which group do you identify yourself (please

select only one)?1. Mexican, Mexican American, Chicano2. Puerto Rican3. Cuban4. Other Caribbean5. Central American6. South American7. Spanish, from Spain8. Mixed Latino9. Other (specify): __________


Demographics– What is your country of birth?

1. Argentina 12. Honduras2. Bolivia 13. Mexico3. Brazil 14. Nicaragua4. Chile 15. Panama5. Colombia 16. Paraguay6. Costa Rica 17. Peru7. Cuba 18. Puerto Rico8. Dominican Republic 19. Spain9. Ecuador 20. Uruguay10. El Salvador 21. Venezuela11. Guatemala 22. United States

23. Other (specify): ____________


Demographics– How old were you when you first came to live in

the United States?AGE: ________


Demographics– In general, what language(s) do you speak?

1. Only English

2. English better than Spanish

3. Both Equally

4. Spanish better than English

5. Only Spanish

7. Don’t Know/Not sure

9. 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 ATSRound 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 3 Honduras• 5 Guatemalan2 Dominican Republic• 4 Puerto Ricans 2 Ecuador• 4 Colombians 2 Peru• 3 Salvadorians 1 Cuban


– Breakdown by Gender:

• Males: 14

• Females: 26


– Breakdown by Education:

• 0 – 8th grade: 7

• 9 – 11th grade: 4

• HS (or GED): 10

• 13+: 19


– Breakdown by Income:

• < $10,000: 4

• $10,000 - $19,999: 13

• $20,000 - $29,999: 4

• $30,000 - $39,999: 7

• ≥ $40,000: 12


– Spoken Language:

• Spanish only: 23

• English only: 4

• Both: 13


– Cigarette Smoker?:

• Yes: 16

• No: 24

Findings From the Cognitive Interviews Terminology


Policy Issues

Demographic Items

Findings From the Cognitive InterviewsTerminology 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 InterviewsSecondhand 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 InterviewsPolicy 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 InterviewsDemographic 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)


TM

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