Smoking among Latino Immigrants: Developing Solutions

Susan GarrettProject Director

A.Paula Cupertino, Ph.D.Assistant Professor

Preventive Medicine & Public Health

November 10, 2010

Global Migration

• 200 million people in the world live outside their country of birth

• The foreign born represented 12.4 percent (35,689,467) of the total population of the United States in 2005

Source: US Census Bureau, 2005 American Community Survey

• Demographics and income differences between countries

• Migration brings development primarily to developing countries but also to wealthy countries

Immigrant Population in Kansas

Immigrant Population in Kansas1990 2007

Number Percent Number PercentTotal Population of

Kansas12,477,574 100.0 2,775,997 100.0

Native born 2,414,734 97.5 2,608,912 94.0Foreign born 62,840 2.5 167,085 6.0

Foreign-Born Population of Kansas2

60,854 100.0 167,085 100.0

Born in Europe 13,113 21.5 13,502 8.1Born in Asia 23,952 39.4 45,080 27.0

Born in Africa 1,232 2.0 9,511 5.7Born in Oceania 511 0.8 202 0.1

Born in Latin America 19,398 31.9 95,897 57.4Born in Northern

America2,648 4.4 2,893 1.7

 

The foreign-born population or immigrants of Kansas changed by 24.0 percent between 2000 and 2007.

Source: Migration P Source: Migration Policy Institute

Immigrant Population and Health

Legal Limits on Health Care Access

• Limited eligibility for Federal Benefits

• In 1996, Congress passed a law that put restrictions on services for both lawful residents and undocumented migrants.

• The most common restriction is that lawful residents have to live in the United States for 5 years before they are eligible for many federal services.

• Many federal programs and social services that serve low-income populations, such as health care, housing vouchers, and cash assistance do not extend to undocumented migrants.

Demographic Characteristics of

Immigrants in Kansas

57.4 % of immigrants in Kansas are from Latin America (South

America, Central America, Mexico, and the Caribbean)

48.5 % were born in Mexico

Age Distribution

6 4 2 0 2 4 6

0 to 4

5 to 9

10 to 14

15 to 19

20 to 24

25 to 29

30 to 34

35 to 39

40 to 44

45 to 49

50 to 54

55 to 59

60 to 64

65 to 69

70 to 74

75 to 79

80 to 84

85 and up

Percentage of Total Population

Population Pyramid - State of Kansas 2006

Sex: Female Sex: Male

8 6 4 2 0 2 4 6 8

0 to 4

10 to 14

20 to 24

30 to 34

40 to 44

50 to 54

60 to 64

70 to 74

80 to 84

Percentage of Total Population

Population Pyramid of Hispanic Population - Johnson and Wyandotte County, 2006

Sex: Female Sex: Male

Geographic Location and Dispersion of Immigrants

United States Race/Ethnicity Projections 2010‐2050

(by percentage)

HISPANIC

WHITE

BLACK

ASIAN

ALL OTHER

2000 2010 2020 2030 2040 2050

24.424.422.322.320.120.117.817.815.515.512.612.6

81.0081.00 79.379.3 77.677.6 75.875.8 73.973.9 72.172.1

12.7012.70 13.113.1 13.513.5 13.913.9 14.314.3 14.614.6

3.83.8 8.08.07.17.16.26.25.45.44.64.6

5.35.34.74.74.14.13.53.53.03.02.52.5

Kansas City, Mexico and Orient Railway Company Routes

Historical Outlook of Latinos in Kansas

Source: Argentine, Kansas: The Evolution of a Mexican-American Community, 1905-1940; Laird, Judith Fincher; 1975, dissertation

Atchison Topeka Santa Fe Section Crew Pauline, Kansas 1913

Fiesta Belles, Topeka, Kansas 1933

Latinos in KansasCounties with Same or Higher Pct. of Hispanic Population compared to Wyandotte Co.

(2005 Census Estimates)

49.5%26.4%

30.3% 37.6% 26.6%

41.5%25.6% 27.8%

45.7%

21.4%

8.4%

9.9%

Health and Latinos in Wyandotte County

Hispanic Birth RatesWyandotte County, KS

• Hispanic birth rate

26.9 per 1,000 population

• Non-Hispanic birth rate

16.5 per 1,000 population

HOSPITAL DIAGNOSIS STATISTICSCOMPLICATONS DURING PREGNANCY

• Complications of pregnancy, childbirth & puerperium

Hispanic – 243.7 per 10,000Non-Hispanic – 120.3 per 10,000

Additionally, nearly twice as many Hispanic mothers report receiving no prenatal care as compared to non-Hispanic mothers.

Source: Kansas Department of Health & Environment, KIC Data

LATINOS ARE MORE LIKELY TO BE UNINSURED

Source: "Finding and Filling the Gaps: Developing a Strategic Plan to Cover all Kansans"; Kansas Insurance Department, August 2001

Note: Uninsured figures are for Region 1 in Kansas which included Wyandotte and Leavenworth Counties.

Race/Ethnicity Under Age 65Pct. Uninsured

Hispanic

White Non-Hispanic

Black

Children Under Age 19

16.8

30.2

10.0

8.7

31.7

11.9

Poverty•Median household income in Kansas - $42.920•Latinos median household income in Kansas - $19.500

Access to Health 26% report that they do not receive regular medical care

when needed

20% rely on emergency rooms

59% on safety net clinics for medical care

61% of employed respondents with benefits do not use them

36% report difficulties finding needed medical interpretation.

Source: Melinda Lewis, 2006

““CIGARETTE SMOKING……is the chief, single, avoidable

cause of death in our society and the most important public health issue

of our time.”

Smoking among Latinos

Cigarette Smoking in the U.S. 2008 National Health Interview Survey

% Men % Women

White African Am Latino Asian Am Indian

23.5 25.6 20.7 15.7 42.3

20.6 17.8 10.7 4.7 22.4

8 years or less 9-11 yrs school high school dipl College degree

24.2 38.1 30.0 11.5

13.0 33.6 21.5 9.7

MMWR 2009;58:1227-1232

Cigarette Smoking Prevalence Study of Latinos Baseline, 2009

National Origin Men (2807) Women (4261)

Cuban 28% 25%

Puerto Rican 38% 34%

Dominican 12% 12%

Mexican 20% 10%

Central Am 18% 9%

South Am 25% 11%

Acculturation and Smoking Behavior in Latino Men and Women

Percent Current Smokers

Men Women

Acculturation Score

1 to <2 (less)

2 to <3

3 to <5 (more)

25.7

25.0

23.0

10.3

11.9

15.5

Light and Non-Daily SmokersTobacco Use Supplement CPS, 2003

% Current % Non-Daily / 1-5

cpd

White African Am Latino Asian/PI

24.5 20.3 14.2 12.3

17/ 5 24/12 35/18 30/14

Nicotine Tobacco Research, 2008

Tobacco Related Disparities

“Differences in patterns, prevention, and treatment of tobacco use; the risk, incidence, morbidity, mortality, and burden of tobacco-related illness that exist among specific populations groups in the United States; and related differences in capacity and infrastructure, access to resources, and environmental tobacco smoke exposure.”

(Eliminating Tobacco-related Health Disparities: Summary Report, USDHHS 2002)

Smoking Cessation Disparities and Latinos

1. Advice from the healthcare providers

2. Pharmacotherapy

3. Behavioral counseling

Clinical Guidelines• The Public Health Service (PHS) Clinical Practice Guideline

for Treating Tobacco Use and Dependence Guideline recommends that a) all smokers be offered treatment, b) patients unwilling to quit be provided with brief intervention to build motivation, and c) patients willing to quit be offered evidence-based treatment.

• Clinic-based intervention should follow five major steps to intervene systematically with patients: Ask; Advise; Assess; Assist; and Arrange.

• The critical first recommendation of the US Public Health Service Guideline on tobacco use and dependence is to identify the tobacco use status of all patients (Ask). None, of the other recommended interventions can occur unless this is done.

Clinical Guidelines cont.• Without consistent identification of smoking status in

the community clinics, there may be a significant number of smokers that are less likely to receive smoking cessation interventions.

• Community clinics play a very important role in providing medical services to patients of low social economic status and minorities. This particular population sees a higher smoking rate than the general population. However, Safety Net Clinics are less likely to perform preventative services because of limited resources and time.

• Hispanics are less likely to receive smoking cessation treatment.

Barriers to Smoking Cessation

• Socioeconomic disparities

• Language/ cultural barriers

• Low health literacy

• Limited access to health care

• Limited access to preventive services

• Health beliefs and attitudes

Study 1

Are Latino smokers getting identified in community clinics

and receiving treatment?

The purpose of this study is to describe the potential reach of smoking cessation interventions in safety net clinics in Greater Kansas City by describing identification of smokers (Ask) across gender, age and ethnicity.

Methods

• We conducted chart reviews of patients (>18 years old) seen during a two week period at three safety net clinics.

• We reviewed intake forms to describe patient demographics and to assess smoking status identification (Ask).

Results Summary• We reviewed 192 medical charts.

• Most patients were female (77.6%) and mean age of 44.9 (SD=13.9). More than half of patients were Latino (52.6 %).

• Latino males are significantly less likely to attend safety net clinics compared to men of other ethnicities.

• Approximately 24% of patients were identified as current smokers.

Results Summary• While there were no differences in being identified

as a smoker across gender and age groups; Latinos (19.8%) were significantly less likely to be identified as current smokers compared to White (42.4%) and African Americans (30.4%).

• Smoking status was not recorded in 12.5% medical charts; Latinos were significantly more likely to have their smoking status not recorded (22.8%) followed by African Americans (8.7%), then whites (3.0%).

Conclusion• While smoking prevalence is higher among Latino

males compared to women, Latino males are significantly less likely to attend SNC compared to men of other ethnicities. Latinos are also less likely to be identified (Ask) as smoker or non-smoker during a regular clinic visit.

• In order to address tobacco-related disparities, we need to better understand smokers’ healthcare utilization across ethnic groups and further improve the reach of clinic-based smoking cessation interventions.

Study 2• Improve utilization of the evidence clinical

guidelines.

• Identifying smokers.

• Referring them to treatment.

The purpose of this study is to assess the feasibility and preliminary outcomes of the Decídete kiosk to improve utilization of smoking cessation resources among patients in safety-net clinics.

Identify Smokers

3. Personalized Health Education

1. Quitline Referral

2. Provider Summary

Outcomes

TWO SAFETY NET CLINICS Methods

PatientProvider

Outcome Measures

Recruitment Kiosk Utilization

Previous Use of Smoking Cessation Resources

Interest in Using Smoking Cessation Resources

2 mo FU

Utilization of Smoking Cessation Resources

163 Referred to Kiosk

128 (78.5%) Consented and Completed the Kiosk

35 (21.5%) Refused

39 (30.5%) Lost to Follow-Up

89 (69.5%) Completed Two-Month Follow-Up Assessment

STRENGTHS WEAKNESSESCounseling from Providers“Pretty impressed. The doctor had mentioned to me before to quit smoking, but this time was different. The way she sat me down at the computer and everything was good.”

“The patient being able to talk with a doctor.”

“Call participants about once a week to check on them. Might be annoying to some people, but some people would find it helpful. Maybe make that an option. Feed this info back to my doctor, she knows I've tried and failed. I know she would call me to talk about it.”

Medication“Receiving the medication for free to help me stop smoking.”

“Finding out what kind of medications are available.”

“I think being able to choose the different meds.”

“Make Chantix available for those who can't afford it. If my doctor hadn't given me a voucher for it I wouldn't be doing so well. I really, really like Chantix and it has helped me a lot.”

“Maybe use over-the-counter medication, not prescription.”

Kiosk utilization“I liked the computer being at the doctor's office.”

“That it was in our language and that other people cared about our health.”

“Made to be convenient. The way the kiosk was set up was easy to use. Made it easy for the providers to help the patient. I'm glad the program offered free medication otherwise I would not have had the resources to do this myself.”

“Letting people input their own information. For example, in my case being able to explain the adverse effects the medications have on me and either having somebody call me back or get that information to my doctor.”

“Mention the great American smoke out and its significance. Show picture of smoker lung versus a non smoker lung.”

Quitline Utilization“The attention I received by the people especially the telephone counselors.”

“I'm not satisfied, I never received a phone call from the quitline.”

Results Summary• Average of 14.29 cig per day (SD=10.88)

• Mean age = 45.25 (SD=10.83)

• 49% Latinos

• 67% Female

• Approximately 50% watched one video; 18% watched both videos

• Highly interested in using medication (9.04, SD=1.66) and quitting smoking (8.79, SD=1.71)

Conclusions

• Decídete software development

• Implementing preventive services in safety net clinics

• Among participants referred to kiosk– Low refusal– High utilization of pharmacotherapy– High utilization of behavioral counseling– High satisfaction

Limitations• Design and implementation

• Reach

– Only 73 smokers

• Latino males

• Office systems

– Staff shortage, turnover

– Staff forgot smoking status screening, missed lots of potential participants

• 2 month follow up assessment

– 30% were lost at the 2 month follow up

– Disconnected phone numbers

– Computer difficulties

Study 3

Community health fairs as an avenue to identify smokers

The purpose of this study is to describe tobacco use and interest in smoking cessation among Latino smokers attending community health fairs.

Methods• Study was conducted within two community health fairs in KC.

• Six bilingual surveyors strategically placed at different screening areas to identify potential participants.

• Surveyors approached adults waiting in line to complete screenings and were invited to participate in the study.

Eligibility criteria:

Self-identified Latinos 18 years or older.

• Consent for participation reviewed in individuals’ language of preference (Spanish or English).

• Participants completed a 15 min survey in participants’ language of choice (Spanish or English).

Defining smokers• Current smokers: those who had smoked more than 100 cigarettes in a

lifetime and had smoked (even a puff) in the past 30 days.

• Former smokers: those who smoked more than 100 lifetime cigarettes but had not smoked (even a puff) in the past 30 days.

• Assessment of current tobacco use included:– number of cigarettes per day (cpd), days smoked within the past

month– time to first cigarette of the day after waking

• Daily smokers: those who smoked 25 or more days in the past month, • Light smokers: those who reported an average of 10 or fewer

cigarettes per day (cpd).

Smoking behaviors

Assessment of previous smoking cessation behaviors included:

– number of previous quit attempts, cessation– treatments used in the past– thoughts about quitting – reasons for quitting– interest in participating in a smoking cessation

program in the future

Results Summary

• 262 (97.0%) participants surveyed were self-identified Latinos

• 53 (20.2%) were current smokers

• Mean age was 37.1 years (SD = 9.3)

• Over half of current smokers were male (54.7%)

• 47.2% annual household income < $20,000

• 79.5% were from Mexico

Light/non-daily smokers

• Most smokers were light smokers (mean 6.0 cigarettes per day, SD = 7.0), non-daily smokers (58.7%)

• 54% smoked their first cigarette after the first hour of waking

• Smoked an average of 17.9 days per month (SD = 12.1)

• 81.3% had attempted to quit at least once in their lifetime

• 64.2% are thinking about quitting within 30 days.

Use of cessation treatment

• Concerns about personal health (64.6%) and the family’s health (25.0%) were cited as the main reasons to stop smoking.

• 94.3% the majority of participants had never heard of free smoking cessation telephone counseling quitlines

• Few smokers reported ever using cessation treatments in previous quitting attempts: only 5.0% had used nicotine replacement therapy (NRT).

• 53.5% expressed interest in participating in free smoking cessation programs to aid future cessation attempts

Conclusion

Health fairs are a potential venue for identifying and engaging Latino smokers to further our understanding of smoking and cessation behaviors among low income, underserved and uninsured Spanish-speaking Latino immigrants.

Academic-Community Based Partnership for Latino Health

What is a promotor?• Promotoras/es are a group of adult community volunteers

who serve in their neighborhoods as liaisons between their peers and their local clinics, schools government etc .

• Promotores de salud are people to whom others naturally turn to for advice, emotional support and tangible aid.

• Promotores de salud have been widely used for effectively delivering health messages to Latinos and improving access to medical services, including smoking cessation resources.

Objectives

• To develop a community-based training curriculum for promotores de salud to enhance knowledge, skills and self-efficacy to promote smoking cessation among Latinos.

• To implement a community-based training curriculum for promotores de salud to promote smoking cessation among Latinos.

• To assess knowledge, skills and self-efficacy pre and post training.

Participants

• 11 Spanish-speaking previously trained promotores de salud were invited to participate in a community-based training curriculum to promote smoking cessation among Latinos.

• Training sessions were conducted at El Centro, Inc.• During the seven, 2-hour sessions, promotores

learned about: cigarette contents and its effects on health, counseling and motivational interviewing, and smoking cessation medications.

• We assessed 15 items on knowledge, skills and self-efficacy pre and post training.

Smoking Cessation trainingTopic Objective

1. Pre-Assessment To assess baseline knowledge.

2. Communication Skills To enhance communication skills.

3. Stages of Change To learn about the different stages.

4. Smoking and Nicotine Dependence To learn about the addictive nature of tobacco use.

5. Smoking cessation medications To learn about smoking cessation medication.

6. Counseling To learn about counseling resources.

7. Talking to community members To learn how to disseminate information.

Promotores activitiesACTIVITIES #

Promotores de salud 11

Latino smokers referred to tobacco quitline 167

Follow-up with smokers interested in quitting 35

Outreach activities (health fairs, Mexican Consulate, local stores and churches) 35

One-on-one contacts 315

Small meetings – information to families and youth 160

Small family meetings 9

Small youth meetings 6

¡Muchísimas gracias!