A Comprehensive Smoking Cessation Program for the San Francisco Bay Area Latino Community: Programa Latino Para Dejar de Fumar

Share Embed

Descrição do Produto

Smoking Control

A Comprehensive Smoking Cessation Program for the San Francisco Bay Area Latino Community: Programa Latino Para Dejar de Fumar Eliseo J. P~rez-Stable Barbara VanOss Mar/n Gerardo Marln

Abstract Background.Prevalence of cigarette smoking amongLatinos comparedto whites is higher among men (30.9% versus 27.9%), but lower among women (16.3% versus 23.5%). More acculturated Latina women, however, smoke more. Comparedto other smokers, Latinos report consumingabout half the average numberof cigarettes per day. Up to a quarter of Latino smokers of less than 10 cigarettes per day may be undevreporting consumption. The association between smoking and depression has also been found in Latinos. Program Goals. The Programa Latino Para Dejar de Fumar (Programa) goals are: 1) to evaluate attitudina~ behaviora~ and cultural differences between Latino and white smokers; 2) to integrate these findings into a comprehensive, culturally-appropriate smoking cessation intervention; and 3) to implement the intervention in a defined communityin order to decrease cigarette smoking prevalence, increase behaviors that may lead smokers to quit, and promote a nonsmoking environment. Program Components. Heightened concern about health effects of smokin~ the importance of social smokin~ and the influence of the family on behavior are integrated in the Programacomponents:1) the promotion of a full-color, Spanish-language, self-help, smoking cessation guide (Guia), distributed at no charge; 2) an anti-smokin~ Spanishlanguage, electronic media campaign; 3) community involvement; 4) quit smoking contests; 5) smokingcessation, individua~ telephone consultations (consultas); and collaboration with health care personnel Results. Effectiveness of the Programais being evaluated by annual, cross-sectional, randomdigit dialing telephone surveys comparedto two baseline surveys. After 19 months of intervention, the proportion who had heard of the Programaincreased from 18.5% to 44.0%, and over one third of less acculturated smokers had the Guia. Future directions will emphasize smoking prevention amongyouth, prevention of relapse amongquitters, and depression prevention. (Am J Health Promot, 1993; 7(6):430-442,475) KeyWords:Smoking Cessation,Community Program,Latino, Minority Eliseo J. Pgrez-Stable, M.D., is an Associate Professor in the Division of General Internal Medicine, Department of Medicine, MEDTEP Research Center on Minority Populations, and Barbara VanOssMarin, Ph.D., is Adjunct Associate Professor, Division of Clinical Epidemiology, Departmentof Epidemiologyand Biostatistics at the University of California, San Francisco. GerardoMarin, Ph.D., is a Professor in the Departmentof Psychology, University of San Francisco. Sendreprint requests to EliseoJ. Pfirez-Stable, M.D., 400 Parnassus Avenue,RoomA-405,Box 0320, San Francisco, California 94143-0320. Thispaperwaspresented at theUniversity of California, SanFrancisco campus, as partof the University of California/ HealthNet Award Lectures.Thisresearch wassupported by PublicHealthSertricegrantnumber CA39260 fromthe National Cancer In.~tituteandby grantnumber HSO7373-O1from the Agency for HealthCarePolicyandResearch. Thismanuscript wassubmitted onOctober 15, 1991,revisea~ andaccepted for publication onApril24,1993.


American Journalof HealthPromotion

INTRODUCTION Cigarette smoking is the leading cause of preventable morbidity and mortality in the United States and in most Latin American countries? Although there has been considerable progress in promoting cigarette smoking cessation and prevention of smoking initiation in the United States, this effort has been most effective among white, non-Latino men and less effective among minority groups and women,z Aware of the changing demographics of smokers, the tobacco industry in recent ),ears shifted its focus towards minority groups in the U.S., those with fewer years of formal education, women, and foreign markets. The disproportionate investment of tobacco industry advertisement in AfricanAmerican and Latino communities supports the contention that these groups have been targeted to s.4 promote smoking, Smoking cessation interventions proven to be effective with whites may not have similar results with minority groups. 5 Tailoring antismoking interventions for a defined racial/ethnic group in order to address culturally relevant issues is more acceptable to minority communities and may be more effective in promoting nonsmoking. This paper reviews the epidemiology of cigarette smoking behavior among Latino populations in the United States, the


role of acculturation in smoking behavior, the significance of ethnic differences in cigarette consumption, and the association of cigarette smoking and depression in Latinos. The background research that evaluated cultural factors in cigarette smoking; the multiple components of an innovative, community-based, smoking cessation intervention for Latinos; and an evaluation plan are described. Finally, limitations of this program, future research and directions, and lessons learned are discussed.

Current Smoking Rates Among Latinos During the past decade regional and national surveys have evaluated self-reported smoking behavior among populations of Latinos (see Table 1).~9 The most recent data from the 1990 National Health Interview Survey ~° showed that the overall prevalence of cigarette smoking is lower for Latinos (23.0)%, 95% Confidence Intervals [CI] -- 21.1

Table 1 Cigarette Smoking Rates Among Latino Adults in the U.S.


Percent Current Smokers Latinos White Non-Latinos Men Women Men Women

1976-1977LosAngeles Health~ Survey





1979CaliforniaHypertension Survey 7 (_>18 yrs.)





1979-1980SanAntonioHealth 8 InterviewSurvey(NHIS)





~ 1979-1982SanAntonioHeartStudy transitional area suburban area

42 31

26 19

40 29

28 33

8 1980NHIS





1° 1981-1983SanAntonio





1981-1983 Behavioral RiskFactors Study11 (BRFS)





~ 1982 TexasBRFSSurvey 18-34yrs. 35-64yrs.

36 37

18 16

36 38

31 31

n,~3 1982-1984Hispanic HANES MexicanAmericans Puerto Ricans CubanAmericans

43.6 41.3 41.8

24.5 32.6 23.2



4 1984-1985NewMexicC





~s 1985HIS





1986-1987Sans FranciscC 17 1989SanFrancisco

32.4 24.8

16.8 12.1

NA 30

TM 1990California BaselineSurvey





~ 1990 NHiS





NA 29

- 24.9) than for non-Latinos (25.7%, 95% CI = 25.1-26.3) and African Americans (26.2%, 95% CI = 24.8 27.6). Within each ethnic/racial group, more men smoked cigarettes than womenand the differential rates by sex were 18.6% for Asian/ Pacific Islanders, 14.6% for Latinos, 10.4% for African Americans, and 4.4% for whites. ~9 The proportion of current smokers among Latino men (30.9%, 95% CI = 27.8 - 34.0) was somewhat greater than for white, non-Latino men (27.9%, 95% CI = 27.1 - 28.9), but a substantially lower proportion of Latina women (16.3%, 95% CI = 14.1 - 18.5) smoke compared to white, non-Latina women (23.5%, 95%CI = 22.7 - 24.2). Smoking rates for the three major Latino subgroups were compared in the Hispanic Health And Nutrition Examination Survey (HHANES) conducted between 1982 and 1984. ~2.~s Sex differences in smoking rates were observed among Mexican Americans and Cuban Americans, but the gap was much less striking among Puerto Ricans. ~’~s Puerto Rican women report smoking at a much higher rate than women in either of the other Latino subgroups examined as part of HHANES.In fact, birth cohort analyses based on HHANESdata estimated that although the prevalence of smoking does appear to be decreasing among Latino men of all three subgroups, smoking rates actually increased among successive cohorts of Latina women, especially among Puerto Rican women. ~ Smoking trends among white non-Latina and AfricanAmerican women in the U.S. have shown a slower decline than for men,~ but a decreasing rate nonetheless, as compared to the increase in the HHANESanalyses. Data on other Latino subgroups are limited, but in San Francisco, Central American Latinos reported similar smoking behavior as Mexican Americans with lower overall rates than white non-Latinos, and up to twice as many men reported current 16 smoking compared to women. Acculturation and Smoking Acculturation to the mainstream

July/August 1993,Vol. 7, No. 6


United States culture is a complex, multidimensional phenomenon that has an important but poorly understood role in manyhealth-related behaviors. ~° Attempts to quantitatively measure multiple aspects of acculturation have resulted in published scales that primarily evaluate self-identity and language use unidimensionally. ~las Although qualitative approaches maybe able to meet the challenge of fully evaluating acculturation, these are usually not practical in population surveys of large samples. Overall, being less acculturated to United States culture seems to have a protective effect on some health related behaviors, especially for women. 16.24.25 The level of acculturation, as measuredby these short, self-report scales, seems to have an important role in influencing smokingbehavior among Mexican-American Latinos. Using a modification of the Cuellar scalefl ~ results from the HHANES showed that smoking prevalence was higher amongthe more acculturated Mexican-American women than amongthose less acculturated.IS Becauseof difficulties in applying this acculturation scale to Cuban Americans and Puerto Ricans, the same type of analyses in these subgroups have not been conducted. A five-item acculturation scale with excellent psychometric properties was applied in a telephone survey of smoking behavior completed by 1,660 San Francisco Latinos in 108687?6 Smokingrates were higher for the more acculturated Latina women but lower for the more acculturated men, and this was observed for both Mexican-Americanand CentralAmerican Latinos. Subsequent surveys in San Francisco have consistently shown lower smoking rates amongless acculturated Latina women,although the acculturation differences for menhave not been as consistent (unpublished data, authors). These data suggest that smoking behavior among Latinos becomesmore similar to that of white non-Latinos with increasing levels of acculturation, and as a consequence, smoking may becomea more serious problem for Latino women. 432

American Journalof HealthPromotion

Ethnic Differences in Cigarette Consumption An encouraging finding from the Is and other surveys 6.~6 was HHANES that Latino smokers, especially Mexican Americans, report smoking an average ranging from eight to 12 cigarettes per day for womenand men, respectively. This number is substantially fewer than the average of 19.1 and 23.4 cigarettes per day reported by white, non-Latino womenand men.~6 The average number of cigarettes smokedby African-American smokers was 14.7 6’~7 for menand 13.5 for womenfl Asian smokers in the 1979 California survey reported smoking an average of 15 to 18 cigarettes per day,7 and, more recently, a San Francisco survey of Vietnamese immigrants showed that smokers on average ~s reported only 12 cigarettes per day. American Indian and Alaskan Native smokers consumed an average of 19.4 cigarettes per day amongmen and 15.5 cigarettes per day among ~ women. In four population-based surveys in San Francisco of nearly 8,000 Latino adults from 1986 to 1989, results also have shownthat Mexican Americans and Central Americans tend to be light smokers, with men reporting more cigarettes per day than women.Level of acculturation was related to the numberof reported cigarettes per day for both men and women. Although a lower proportion of highly acculturated mensmoke, they report a greater numberof cigarettes per day than less acculturated men. ~6 Among women, a higher proportion smoke and report smoking more cigarettes per day as acculturation level increases. 16 These observations have important implications for cessation strategies since, comparedto heavy smokers, light smokers are more likely to successfully quit smoking with appropriate motivational messages and self-help methods. There are several possible explanations for the observed differences in self-reported cigarette consumption amongethnic groups. One possible explanation is that there are ethnicspecific differences in the rate of

nicotine metabolism and elimination. This would mean that a smoker from a group with slower metabolism could achieve a similar average level of nicotine by consuming fewer numberof cigarettes. Slower metabolic and elimination rates of nicotine maymakespecific populations more vulnerable to nicotine addiction and its adverse health effects with fewer cigarettes smoked per day. A second possible explanation is that smokers from certain ethnic groups consider cigarette use to be a socially undesirable habit, and as a consequence, they underestimate and underreport their cigarette consumption. If underreporting occurs, then a larger proportion of self-reported light smokers amongethnic minorities are at higher risk of cardiovascular disease and cancer, and more intensive smokingcessation interventions would need to be developed for these populations. A third possible explanation is that ethnic minorities smokefewer cigarettes because of financial constraints but smokethose cigarettes more efficiently. Thus, extremely efficient smokingby self-reported light smokers(e.g., less than 10 cigarettes per day) mayachieve, with fewer cigarettes, similar nicotine levels to those seen in people who smoke two to three times as manycigarettes per day. Finally, smokers from minority groups may actually smoke fewer cigarettes, be less dependent on nicotine, and thus havea less difficult time in quitting. Underconsumption or Underreporting of Cigarettes by Latinos? Validation of self-reported smokingbehavior is a well established research tool in evaluating quit rates amongsmokers following any s° type of cessation intervention, Althoughattempts to evaluate selfreported smoking behavior with a biochemical measure have only recently been conducted in other population groups, the low number of cigarettes reported by MexicanAmerican smokers and the tendency for Latinos to give socially desirable

responses sl raised the concern that underreporting may be occurring. In order to address this question, a recent study compared selfreported cigarette consumption with serum cotinine levels in a sample of 547 Mexican-American smokers s~ participating in HHANES. Cotinine is a specific metabolite of nicotine and has a 20-hour half-life thus allowing measurement of steady state levels even after not smoking cigarettes overnight. ~° Underreporting was defined by a cotinine to cigarette-per-day cutoff ratio that represented a substantial discrepancy between self-reported consumption and serum cotinine, ss’a4 Results showed that while the overall cotinine levels were lower than reported for community-based samples of white non-Latinos, approximately 21% of men and 25% of womenreporting less than 10 cigarettes per day were estimated to be underreporting cigarette consumption s~ (see Figure 1). The estimated range of cigarettes per day underreported varied from two to 17 and was based on the expected range of serum cotinine per cigarette smoked. Among those smoking 10 to 19 cigarettes per day, an estimated 10% were underreporting while among smokers of 20 or more cigarettes per day only 2% to 3% s~ were apparently underreporting, These data would imply that a larger proportion of Mexican-American

smokers may be more addicted to nicotine than was evident from selfreport surveys. Since cigarette smoking is considered a cardiovascular risk factor when 10 or more cigarettes are smoked per day, these results would imply that a larger proportion of Latinos are at risk than previously thought. In addition to the analyses among Mexican Americans, investigators from the Coronary Artery Risk Development In young Adults (CARDIA) study have reported racial differences in serum cotinine levels among smokers2 ~ After adjusting for possible confounders, African-American smokers in the CARDIAstudy had a median level of cotinine of 221 ng/ml compared to 170 ng/ml for white smokers (A=51; 95% CI for difference of 34 to 65 ng/ml). The investigators suggested that this difference was due to differences in metabolism of nicotine or the excretion of cotinine, s~ If this hypothesis is confirmed, racial or ethnic differences in nicotine metabolism may account for lower cessation rates and higher rates of some smoking-related cancers in African Americans. The possibility of underreporting needs to be evaluated in other groups of light smokers to determine if it is related to cultural issues, genetics, or if it is a generic behavior characteristic of light smokers. A study is currently underway to

Figure1 Percent of Apparent Underreporters AmongMexican-AmericanSmokers, HispanicHealth andNutritional Survey1982-1984 %25%20%15%10-

[] ¯

%5¯ %0 ~ sex: cigarettes p~r day:

’ 1 men 1-9


2 women 1-9





3 men

4 women

5 men

6 women



~ 20

~ 20

evaluate possible differences in the metabolism of nicotine and clearance of cotinine among light and heavy smokers who are white non-Latinos, Mexican and Central Americans, African Americans, and Chinese Americans (personal communication, E.J. Perez-Stable and Neal Benowitz). Cigarette Smoking and Depression There is a strong epidemiologic and clinical association between cigarette smoking and significant depressive symptoms or clinical depression. National data from the Health and Nutrition Examination Survey Epidemiologic Follow-up Study reported that 10% of smokers with significant depressive symptoms compared to 17% of those without significant symptoms were able to s6 quit after nine years of follow-up, The association between smoking and depression is further supported by a longitudinal study which showed that depressed adolescents at 15 to 16 years of age in NewYork public schools were more likely to be heavy cigarette smokers than non~depressed adolescents when followed up nine years later, s7 Other suggestive evidence came from a clinical trial of clonidine as a pharmacologic adjunct to smoking cessation in 71 heavy smokers, which showed that 61% had a history of major depression and that this history had a significant negative effect on cessas~ tion regardless of treatment, Subsequent clinical studies have found a higher relapse rate among smokers attempting to quit who had a past history of major depression and an increased risk of a new episode of major depression, s° It is believed that some people may be treating their depressed moods with nicotine. An association between cigarette smoking and significant depressive symptoms was also found in a sample of San Francisco Latinos surveyed in 1988. 40 The Center for Epidemiological Studies Depression (CES-D) Scale was administered to 551 San Francisco Latinos as part of a random digit dialing telephone survey to evaluate smoking behavior. July/August1993,Vol. 7, No.6


For both men and women, current smokers had the highest mean CESDlevels (9.7 and 14.4, respectively). The proportion of current smokers with a significant level of depressive symptomswas substantially greater than for former smokers or never smokers (see Figure 2). Logistic regression analysis controlling for sex, acculturation, education, age, and employment showed that current smokers had an adjusted odds ratio (OR) of 1.7 (95%CI = 1.3 2.2) for significant depressive symptoms compared to former smokers (OR= 1.1; 95%CI = 0.8 - 1.6) and never smokers (OR-- 1). The interaction of nicotine dependence and significant depressive symptoms and howthis effects cessation needs further study at both the individual and communitylevels. PROGRAMA LA TINO PAPA DEJAR DE FUMAR The San Francisco Bay Area Latino Community The San Francisco Bay Area is made up of the nine counties surrounding the Bay and is home to over six million persons in a single electronic media market. The Bay Area is one of the most diverse cultural settings in the U.S. The city and county of San Francisco is the commercial and cultural center of the metropolitan area with a popula-

tion of 723,959.41 Latinos live throughout the area but are concentrated in the cities of SanJose, Hayward,Union City, Daly City, and San Francisco. Results from the 1990 U.S. Census showed that in San Francisco, white non-Latinos comprise 46.6%of the population, Asians 28.4%, Latinos 13.9%, African Americans 10.5%, and American Indians 0.4%. Although the majority of Latinos in California are Mexican American, due to immigration patterns of the past 20 years, an increasing proportion of Latinos in the San Francisco Bay Area are from Central America. The 1990 census found that amongSan Francisco Latinos, 40.5%are Mexican, 4.7% are Puerto Rican, 1.5% are Cuban, and 53.3%are classified as "Other Latinos" of whomthe majority are 41 Central American. The target area for the Programa Latino Dejar de Fumar(subsequently referred to as Programa)community intervention was defined by the 50 census tracts in San Francisco with at least 10%Latinos in the 1990 U.S. Census and includes nearly 70%of the adult Latino population. The MissionDistrict is the core neighborhood of the target area and contains a combination of modest Victorianstyle houses, a commercialretail business district, and an industrial area with warehouses and small factories. Approximately 50%of the MissionDistrict population is Latino,

Figure2 Significant DepressiveSymptoms by Smoking Status Among SanFranciscoLatinos, 1988 25 2O 15

NeverSmokers %CES-D scores >16



American Journalof HealthPromotion


with a median age of 30.5 years and 14.3% of the households headed by 41 About two thirds of the women. Latino adults prefer to speak Spanish and about a quarter do not speak English well. Within the Mission District are located almost all of the established Latino organizations and social networks in San Francisco. These include Catholic and other Christian churches, merchant associations, legal aid and immigrant groups, adult education centers, youth groups, a cultural and arts center, and social clubs. The Mission Neighborhood Health Center has been of special importance to the Programaand is the principal site for health care for poor persons in the neighborhood of whomabout 80% are Latino. The Health Center has strong communitysupport and is the main focus of any health care issues relevant to Latinos. Finally, the Mission Economic and Cultural Association (MECA) is an influential organization which has been a major organizer of communityevents and has longstanding relations with the business community. Organization and Budget The Programawas funded by the National Cancer Institute in 1985 as part of a special initiative to develop and implement smoking prevention and cessation interventions for Latino populations. The original five-year award (1985-1990) was for $1.6 million and the competitive renewal award (1990-1995) was for $2.0 million. A physician, a health psychologist, and a communitysocial psychologist direct all Programa activities. The three full-time equivalent personnel who implement most intervention components consist of two college educated research assistants and a master’s level person. There are weekly meetings of investigators and staff where most decisions affecting the intervention are made. Using the 1993-94 budget plan to estimate costs, the overall cost of the Programaintervention activities (excluding administrative, {esearch, and evaluation aspects) is projected

to be $170,000 for the year. The breakdownof individual intervention componentsis as follows: $98,000 in salaries and benefits of personnel implementing the intervention; $25,000 in the television media campaign; $23,000 in the radio media campaign; $14,000 in rent; and $10,000 in contests, printing, supplies, postage, and telephones. Based on a Latino population of 100,717 in San Francisco, the costs of the intervention per person in the communityper year is estimated at $1.70. Of great benefit to the Programa is the fact that a major intervention component, the Guia Para Dejar de Fumar,has been available in large quantities from the state of California free of charge. The Guia was produced originally for about $2 per copy. Background Research Health promotion in the prevention of cardiovascular morbidity and mortality will primarily dependon behavioral lifestyle changes. In order to begin to develop interventions applicable at the communitylevel or in clinical circumstances, knowledge, attitudes, and beliefs regarding behavior related to these outcomes must be evaluated. The importance of developing culturally- appropriate interventions extensively pretested in the targeted communityhas to be emphasized. This background research was essential in the development of a smoking cessation community intervention for Latinos in San Francisco. The Programawas launched as a communitywidesmoking cessation intervention in the San Francisco Bay Area in November1987. The design and content of the smoking cessation intervention was developed after two years of basic research evaluating attitudinal, behavioral, and cultural differences between Latino and white, non-Latino smokers. This research focused on smoking behavior, cigarette smokingas an addictive behavior, attitudes towards quitting, stereotypes about smokers, awareness of the adverse health effects of cigarettes, and level of information of howto quit or howto

obtain help in quitting. 4~’~7A summaryof the major findings in the comparison of smoking behavior and culture between Latinos and white non-Latinos follows. Latino smokers in San Francisco were found to average 12 cigarettes per day comparedto 21.5 for white non-Latinos and by implication have a lower level of nicotine dependence. Furthermore, only 26%of Latinos smokedtheir first cigarette of the day within 30 minutes of waking compared to 55% of white nonLatinos. 46 Comparedto white nonLatinos, Latinos were more likely to believe that they could go a whole day without smokingand that it wouldbe easy to quit. 46 Although Latinos reported having less information on where to obtain information on cessation services, they also . perceived less of a need for help in quitting and felt more capable of quitting on their own.In fact, the most frequently cited methods by Latino smokers in helping them quit was voluntad propia or will power and knowingthe negative effects of smoking. These findings were consistent with the hypothesis that Latinos are less dependent on nicotine and maybe more likely to quit on their ownwith brief interven46 tions or self-help guides. Compared to non-Hispanic white smokers, Latinos perceived their smoking to be less dependent on situational cues such as drinking coffee, watching television, or while on the telephone. Social cues such as being at a party, with friends, with other smokers, or while drinking alcoholic beverages were equally likely antecedents of smoking perceived by Latinos compared to white non-Latinos. However, the importance of cigarette smokingwith a groupof friends or at a social gathering was heightened for Latinos when compared to white nonLatinos. Finally, Latinos and white non-Latinos were equally dependent on emotional cues to smokesuch as 4~ when nervous or worried. Latinos were more concerned about the effects of smokingon interpersonal relationships, especially within the family. The per-

ceived consequence of harming the health of their children by continuing to smoke was heightened among Latinos compared to white nonLatinos. Furthermore, Latinos were morelikely to cite giving a better exampleto their children and improving relations within the family as a perceived consequences of quitting smoking.4~ In another study of medical patients whosmoke, Latinos compared to whites were also found to have a heightened motivation to quit smokingin order sto protect their children? From these observed differences in attitudes, beliefs, and behavior about cigarette smoking between Latinos and white non-Latinos, three major elements were integrated into the smoking cessation community intervention. First, the lower dependence on nicotine encouraged a minimalintervention strategy based on a public health model to promote voluntad propia. Second, the cultural concept of familialism O’amilismo) which was found to persist in second and subsequent generations of Latinos, ~9 was incorporated into all aspects of the intervention. Thus, the message would focus more on quit smokingfor your children or for your family rather than just to quit smoking for your own benefit. The appeal had to be to the entire family unit and thus appeal to a collective loyalty that often ranks higher than individual needs. In addition, Latino family members often encourage smokersin the family to quit. Finally, the cultural script of Latinos described as simpatia~° was incorporated into the Programa.Simpatia translates as an expectation for more frequent positive social interactions and less frequent negative interactions. Thus as a central theme, simpatia implied an intervention that emphasizedpositive aspects of quitting, pointed out the negative effects of smokingon social interactions (bad breath, smell), and avoided a confrontational message with respect to nonsmokers’rights. The smoking cessation interventions consistently emphasizethe family unit and positive personal interactions with Latinos as role models and July/August 1993,Vol. 7, No.6


communicators for all activities.

cope with these, and a section on dealing with relapse situations. A second edition of the Guia titled Fumar:UnJuegoPeligroso... was published in late 1991 containing an extensive revision of all aspects of the first edition. (The second edition was produced with money received from the Health Protection Act, Tobacco Taxes of 1988-Proposition 99, under grant 90-11575 of the state of California). This new edition adds sections on management of mood during cessation, on how a nonsmoker can help a smoker quit, and on the availability of nicotine substitution treatment for withdrawal symptoms. The inclusion of a section for nonsmokers was a result of experience with the first edition that frequently the first person to seek information about how to quit was a male smoker’s wife or mother. Free distribution of the Guia

Implementation of the Community Intervention The smoking cessation community intervention attempts to saturate the Latino community in San Francisco with culturally-appropriate information about why and how to quit smoking. Standard use of broadcast Spanish that avoids regional idioms has been incorporated into all of the media components. In addition, Latino physical types that represent all varieties of Latin American national groups have been used as models and communicators. The intervention has been designed by Latino researchers, and each component has been revised after extensive pretesting with the target community. The major components that have been developed are summarized as follows and shown in Figure 3. Self-Help Strategy: Guia Para Dejar de Fumar Surveys of former smokers have identified that at least 90%have quit 51 without any formal program. Given the persuasive evidence that, in general, Latinos are light smokers and that minimal intervention strategies are more likely to be used by a 5~ high proportion of current smokers, development of an effective self-help method became the priority. Informal interviews and focus groups with Latino smokers indicated that an attractive publication with color photographs providing the most important reasons to and methods to quit smoking was preferred. The first edition of the Guia Para Dejar de Fumar (subsequently referred to as Guia) is a 36-page, Spanish-language, smoking cessation self-help guide with full color photographs throughout. 5s The Guia was developed by adapting a compendium of self-help techniques and integrating the cultural issues identified as a result of the background research. It includes a section on motivation, a menu of techniques to decrease nicotine dependence, recommendation to quit cold turkey, a description of withdrawal symptoms and how to 436

throughout the Latino community has been the principal component of the community intervention to promote smoking cessation. As of January 1993, about 100,000 Guias had been distributed through community health centers, hospitals, physicians’ and dentists’ offices, pharmacies, schools, stores, restaurants, and during community arts and music festivals. The Guia has been distributed at 48 different types of small businesses with a total of 486 participating locations in the Latino community. Catholic and Protestant churches have also been involved in the distribution of the Guias and in promoting anti-smoking activities with their members. A full-time project assistant devoted up to 50% of his time to Guia distribution within the census-tract-based intervention community. Distribution of the Guia during the remainder of

Figure 3 Major Components of ProgramaLatino Para Dejar de Fumar

1987 GulaPara Dejar de Fumar Guia1st edition Guia2ndedition Media Campaign Spanish"IV announcements SpanishRadioannouncements Radioand"IV talk shows Posters,buscards, flyers Newspaper articles CommunityOutreach LocalOffice AdvisoryBoard Othercommunity organizations Slide-tapeshow Health fairs Community festivals Great AmericanSmokeout Quit SmokingContest CessationGroupsand Consultas Cessationgroups Consultas Health CareProviders Document distribution Guiadistribution

AmericanJournal of Health Promotion




the communityintervention has shifted from massive saturation to specific targeting such as through health care settings, especially supportive local businesses (e.g., smoke-free restaurants) and at community events. Media Campaign Encouragedby the evidence that mass media can be an effective intervention to promote nonsmoking in mainstreamU.S. society ~4 and in Australia,55 the Programa also focused on an anti-smoking media campaign. Thus, the second major component developed and implemented in the community intervention was through the Spanish-language electronic media. Initially consultation was sought from a Latino marketing expert who facilitated several contacts. However, the Programawas introduced to the Latino media by Latino researchers who represented two prestigious academicinstitutions and offered a specific service to the communityat no charge. Under these circumstances the Spanish-language media found initial requests for airtime very difficult to refuse. Working with the Spanishlanguage electronic media had three major advantages. First, because tobacco advertising is banned in the electronic media, managersat these businesses were receptive and cooperative, unconcerned about economic consequences. Second, the novelty of the anti-smoking message in Spanish-language media in 1987to 1988facilitated a portal of entry through popular radio talk shows to present the most basic elements of the campaign. Finally, the Spanish-language media market is considerably less competitive and less expensive than the Englishlanguage media market and thus affordable within a limited budget. For example, the San Francisco Bay area has a total of four radio stations and two television stations that broadcast in Spanish, and the option to purchase time on the air was at least feasible within the Programa’sbudget. Overthe past five years, 15 television and over 70 radio public service announcements (PSAs)

Spanish have aired on all of the major Spanish-language radio and television stations in the San Francisco Bay area sponsored by the Programa. These PSAs were written and partially produced by Programa staff and contain culturally-appropriate messagesabout cigarette smoking and how to quit. Community leaders addressing the disadvantages of smoking and former smokers talking about whythey quit and what benefits have been gained were frequently featured. The PSAs contain vignettes related to real life issues in the community,staged to illustrate a point related to smoking cessation. One PSAshows a delighted Latino mother reading a letter from her son whowrites that he has quit smoking on Mother’s Day because of his children. Another PSAemphasizes the unpleasant cigarette smell that accompanies smokers when visiting nonsmoker friends. PSAsthat use established community role models providing personal testimony as to how and whythey quit smoking have also been produced. These radio and television PSAshave been played several times per day on the Spanishlanguage stations with about one third of the time purchased and two thirds of the time donated. Programapersonnel have also been invited guests on radio talk shows about once a month including one with the largest listening audience in the San Francisco area. The format is based on an initial conversation between host and guest followed by listeners calling in to participate in lively discussions. The dissemination of specific information regarding smoking and quitting has been the central element of these radio talk showdiscussions. In addition, community members with specific experiences in quitting smokingand recognized communityleaders have volunteered to provide their testimonies on the air. The PSAshave successfully used the heightened importance of physicians as authoritative experts in Latino culture~6 by featuring question and answer sessions on the air with a Latino clinician to address smoking-related

concerns as well as other health care issues. The use of printed media has emphasizedculturally-appropriate messagesin a visually attractive format of pamphlets, posters, flyers, and billboards. An initial pamphlet was developed to promote motivation and was targeted for smokers only. Subsequently, a separate pamphlet was published targeting nonsmokingmembers of a family, in order to utilize the powerful familialism characteristic of Latinos. These messages have now been incorporated into the second edition of the Guia. Over 1,000 posters showingthe cover of the first edition of the Guia were distributed and a poster with the cover of the second edition has been produced and distributed. These posters are placed at key sites of Guiadistribution and given to individuals whorequest them to place in their homes. Duringthe first two years of the Programa,about 50,000 flyers with brief messages promoting nonsmoking were produced and distributed to individuals and businesses throughout the Latino community. However, this strategy was abandonedin favor of greater emphasis on Guia distribution. Finally, stationary billboards and external and internal billboards on city buses were purchased over a two-year period. During a 12-monthperiod, six to 10 smokingcessation billboards per month were featured and 60 buses had external billboards advertising Por su Familia...No Fume(For your Family...Don’t smoke)with the Prog~’amaname and telephone number. The relatively high cost of billboards ($12,000 for six months), the competition fi’om cigarette manufacturers for billboard space, and the lack of any evidence that billboards offered any specific advantages resulted in abandoning this strategy. The state of California sponsored anti-tobacco media campaign has used Spanish-language billboards to promote nonsmoking. Efforts to publish newspaper articles on the adverse health effects of smoking or to promote the Guia were for the most part stifled by July/August 1993,Vol.7, No.6


passive resistance from local editors. Hours of work to write newsworthy stories based on new research and how this information may apply to Latinos often resulted in a published article gutted by the editor or permanent postponement of publication. Local newspaper editors expressed interest in publishing a regular column only if paid advertisements were part of the package. The fact that the San . Francisco Bay area does not have a Spanish-language daily, that most Spanish-language newspapers have a limited circulation, and that our own research showed that the most widely read newspaper by Latino smokers ~7 was the English-language daily resulted in less and less use of local newspapers. Community Outreach Recognizing that a media intervention alone may not suffice, community organization and presence has been an integral part of the intervention. Although the Programa is directed from academic institutions located several miles from the Latino neighborhood in San Francisco, a communitysite was established from the beginning of the project. Limited office space was rented during the first five years in the Mission Neighborhood Health Center which is the principal community clinic providing service for Latinos. Subsequently, offices were moved to commercial space located in the heart of the Mission District. An advisory board of community leaders was initially formed and included a staff member from the local Latino political representative, a business owner, health care officials, media representatives, and community organization volunteers. Meetings were held every four months for the first two years, and the advisory board was consulted about the planned intervention strategies. Subsequently, formal board meetings were discontinued, but Programa staff maintain strong ties to many of the individual members. In addition, the staff began to participate in a number of community-oriented organizations decreasing the need to hold separate meetings. 438

AmericanJournal of Health Promotion

The first community outreach tool developed was an eight-minute slidetape show that illustrated the importance of quitting smoking, provided counter-arguments to the common excuses given by Latino smokers for not quitting, and provided information about the Prograraa. This show is in both slide-tape format and videotape and was used widely to introduce the Programa to community groups during the first two years. Public presentations on the adverse effects of smoking and how to help smokers quit were made to approximately 70 community organizations and at 18 adult education settings. These served the purpose of systematically introducing the Programa to the community and establishing a presence. This has been followed up by efforts to involve as many persons as possible in the smoking cessation intervention. Distribution of the Guia has been used as the major element to facilitate discussion of smoking issues on an interpersonal level. The Programa has been present at each of three annual major community festivals to celebrate Cinco de Mayo, Carnaval in June, and celebration of Mexican and Central American independence from Spain in September. A booth is rented for the duration of the festival and staff distribute the Guia and other literature related to nonsmoking such as buttons, pens, or nonsmoking signs with the Programa name and telephone number; recruit volunteers for related studies; and talk to as manypersons as are willing to listen. Programaparticipation at these events has often defied active sponsorship by the tobacco industry featuring popular dance music, attractive young people promoting smoking, and distribution of free cigarettes. In the last three years, overt sponsorship by the tobacco industry has been more limited and in some cases completely eliminated. The Great American Smokeout sponsored by the American Cancer Society has been a focal point of community activities since 1988. An information table is located all day in the busiest intersection of the Latino

community accompanied by local media coverage. Other activities related to The Great American Smokeout included a smoke-free dance, special radio programs, distribution of specially produced buttons, and collaboration with other groups in nonsmoking community coalitions. Using a similar format the Programa has also participated in health fairs sponsored by the Mission Neighborhood Health Center, San Francisco General Hospital, Saint Luke’s Hospital, Macy’s Department Store, and the Health Department Tobacco Coalition during the past four years. Quit Smoking Contest In 1988, a quit smoking contest or rifa that offered cash prizes as a way to motivate current smokers to quit was launched. The rifa idea was borrowed and adapted from other experiences. ~s Furthermore, in doing community outreach, prizes donated by supportive local businesses had been given away at special events and thus found that a concrete material reward was a potential, strong motivator to quit smoking. In each of the seven contests sponsored by the Programa to date, one to three smokers were eligible to win a $250 to $500 cash prize. In pretests of the quit smoking contest format, a need for simplification of procedures was identified, and currently we have an approach that appears to be useful with Latinos. Participants complete a form providing their name, address, telephone, age, birthplace, number of cigarettes smoked per day, and the name of a close friend or relative who can testify as to their smoking status. Biochemical validation of abstinence from cigarettes by a saliva cotinine test is required before winners are confirmed. Recruitment of 300 to 400 smokers for each of the r/f as was conducted through PSAs, personal contacts with community members, promotion through cessation groups, flyers, and as part of community outreach activities. Up to 80% ofrifa participants have been men, and, thus in our experience, this has been one of the most effective means of

reaching male smokers. The winner is announcedon a local radio station programand often volunteers for a PSAor other Programaactivities. These quit smokingcontests are open to potential participants for up to five monthswith deadlines set to coincide with January 1 and Mother’s Day. The connection of quitting smoking for the NewYear or for the family has facilitated promotion of the contests. The possibility of entering the contest has been a good motivator for people to attempt to quit and, whenthat is difficult, to obtain other assistance such as from cessation groups. Cessation Groups and Consultas Based on the background research, dozens of interviews with smokers, and the initial experience of working with the community, Programainvestigators developed a Group Leader’s Guide for conducting smoking cessation groups with Latinos. This group intervention was designed to be applied in four, onehour sessions and adapted elements from several English-languagecessation groups. At the time that this cessation group intervention was being developed there was no experience in working with Spanishspeaking Latino smokers in the existing cessation programsin the San Francisco Bay Area. Although the lack of information about cessation techniques may have contributed, most Latino smokers approached were unwilling to attend multiple sessions of a group intervention to quit smoking.In fact, in order to adequately pretest the content of the cessation groups, seven Latino smokers were paid $40 each to attend six sessions. Even though the content was deemedculturally-appropriate and understandable by the participants, the cessation groups had limited acceptability. During a two-year period, free smokingcessation groups were offered during lunch hour and evening time periods at conveniently located sites in the MissionDistrict. These cessation groups were widely promoted through flyers and radio programs. Despite this effort only about 100 smokers volunteered to

attend at least two sessions whichis about an average of one to two persons per week. After evaluating the required personnel time for such a limited group of smokers, the regularly scheduled cessation groups were abandoned. Distribution of the Guiain the communityled to many one-to-one interactions about quitting between Programastaff and Latino smokers. Subsequently, a structured smoking cessation counselingsession (consulta) that can be up to 20 minutes long was offered to smokers over the telephone or in person. The main staff person providing the consultas is college educated and was trained by a health psychologist. The smoker is guided through steps promoting cessation including a discussion of whythe person wishes to quit, and what techniques the person has used and could use. This approach offers the advantage of being time efficient, allows for a muchwider dissemination of quitting techniques, and is tailored to the individual needs of the smoker rather than requiring attending a group session. Even if the cessation rate was considerably lower than for group interventions, consultas theoretically should be more cost-effective. The telephone consultas are most often initiated by Programapersonnel, but they are also requested by smokers who are unable or unwilling to travel to and participate in multiple sessions of a cessation group. To date, we have conducted over 300 consultas with Latino smokers. As part of the cessation group intervention, a series of Spanish-language audiotapes to promote non’smoking were developed. These tapes included professionally enacted vignettes illustrating the principles of relapse prevention, relaxation techniques, and assertiveness when coping with social temptations to smoke. Despite the low frequency of cessation groups, these audiotapes have continued to be in demand and segments have been presented on the radio. Health Care Providers Whenthe community intervention began, we contacted 300 physicians

and dentists whowere practicing in areas of San Francisco with a significant number of Latinos, had Spanish surnames, or were listed as speaking Spanish by a professional organization. A letter describing information about Programaservices and a copy of the Guia, with an offer to deliver more copies was mailed to each health care professional. A copy of a document titled "Helping Latino Smokers Quit: A Guide for Health Care Providers" was also mailed to each office. The "Guide for Health Care Providers" adapts interventions developed by other researchers to help physicians and dentists counsel their patients on howto quit smoking to use with Latino smokers. An offer to provide small group seminars to practicing clinicians has had a limited response outside of the training institutions. Pharmacists and public health nurses have subsequently also received these materials on request. To date, we have distributed 10,000 Guias through health care settings in the Latino community. Although the Mission Neighborhood Health Center and the San Francisco General Hospital have been the principal sites, weare currently distributing the Guia through an additional 50 private physician and dentists offices or pharmacies. EVALUATION OF THE PROGRAMA LATINO PARA DEJAR DE FUMAR Evaluation Plan The ProgramaLatino para Dejar de Fumarcommunityintervention is being evaluated by cross-sectional telephone surveys of the defined census tracts. Twosurveys were completed prior to launching of the intervention and these data will form the basis for future comparisons. In addition, a cohort of smokers and former smokers have been followed since 1989 in order to add another dimension to the evaluation of the intervention. The cohort data will also provide information on spontaneousrelapse rates, reliability of ascertaining smokingstatus by telephone interviews, and variability July/August 1993,Vol. 7, No.6


in self-reported smokingbehavior in Latinos. Unfortunately, there are no available data from a control community to evaluate the natural history of smoking behavior in a comparable, "no intervention" setting. Without a comparison control community, .generating persuasive evidence that the Programais effective in promoting nonsmokingmay be difficult. In fact, the voter-approvedincrease in cigarette taxes in California in 1989 and the resulting smoking cessation and prevention campaign further confounds dissecting which intervention componentwas effective. In an effort to evaluate the impact of the communityintervention, we used the survey data to define a predictor variable labeled "Programa exposure." This consisted of "yes" responses to questions about recognition of the Programaname; having the Guia; having seen or heard messages about a program to help Latino smokers quit on television, radio, in newspapersor posters; and, beginning in 1989, knowing about the rifa. Each respondent who had heard of the Programawas classified as to level of exposure being either none, low (1 to 4 yes responses), high (5 to 7 yes responses) exposure according to the number of components recalled during the 12 months preceding the survey. Changes in Information and Awareness of Cessation Services Four randomdigit dialing crosssectional surveys of 1,660, 2,053, 1,965, and 1,989 Latinos between 18 and 65 years of age were completed in the Programatarget area in 1986, 59 1987, 1988, and 1989, respectively. The first two surveys provide the baseline to whichfollow-up results will be compared. The data showed that a number of important changes have taken place in information about and awareness of the Programa. In each of our surveys, we have asked whether the respondent has heard of the ProgramaLatino Para Dejar de Fumar. While 18.5% and 21.9% of respondents had heard of us in the two baseline surveys, 35.8% and 44.0% had heard of the Programa seven and 19 months after initia440

tion. ~9 Moreimportantly, the proportion of current smokers who had heard or read about the Programaincreased from 12.6% and 15.3%at baseline, to 31.7%and 52.0%after seven and 19 months of communityintervention, respectively39 Evaluating these data by acculturation level showedthat 53% of the less acculturated Latinos had heard of the Programaby 1989, compared to only 11%of the more acculturated. This compared to 25% and 8%,respectively, at baseline surveys.59 This finding by acculturation level is not surprising, since acculturation is closely associated with language use, and the campaign has been conducted almost exclusively in Spanish. The proportion of current smokers reporting having a copy of the Guia at the time of the 1988 survey was 12%of the less acculturated men and 23%of the less acculturated women.Results from 1989for the less acculturated show that 34.1% of men and 37.7% of womenwho report smoking have the Guia. ~9 Thus, a substantial proportion of Latino smokers in San Francisco were able to state that they had a copy of the Guia. Evaluation of the Guia Para Dejar de Fumar The first edition of the Guiawas evaluated for acceptability and effectiveness in achieving cessation without a randomized design. A total of 431 smokerswere identified when they returned a postcard included in the Guiaoffering a prize regardless of smoking status. These smokers were evaluated approximately at a meanfollow-up of 2.5, 8.2, and 14 monthsafter receiving the Guia. Self-reported quit rates declined from 21.1%, to 18.6%, to 13.7%after 14 months.6° Of the 59 smokers who reported to have quit during a telephone interview, 37 provided a saliva sample, for cotinine analysis and 36, or 8.4%, of the original sample, had a validated quit status at the end of follow-up. Womenand persons older than 44 years of age were more likely to remain nonsmokers, but the number

American Journalof HealthPromotion

of cigarettes per day, perceived social support for quitting, and the presence of a smoking partner did 6° not predict validated quit status. The most mentioned components of the Guia were the graphic photographs showingthe adverse effects of smoking on health, the health emphasis, and the overall format. The Guia is an appropriate and effective self-help smokingcessation booklet for Spanish speaking Latinos in the U.S3° An evaluation of the second edition, FumarUnJuego Peligroso.... with Latino smokersusing a randomized design outside of the communityintervention target area, is currently being completed. Future Directions The communityintervention will continue with its current components through 1994. In order to strengthen the intervention and expand its impact, two major new components are planned. First, smoking prevention interventions targeting Latino youth outside of the school setting will be developed. Specific componentswill be based on results of census-tract-basedinterviews with Latino and white nonLatino adolescents to evaluate cultural differences and similarities in attitudes, beliefs, and behavior about cigarette smoking. Epidemiologic data indicate that Latinos initiate smokingat a similar age as non-Latinos, and rates amonghigh school seniors have not decreased. The second area of expansion is based on the observed association between cigarette smoking and significant depressive symptoms. After incorporating a Latino investigator with expertise on depression to the research team, the connection between depression and cigarette smoking prevention messages has been introduced as part of the communityintervention. A specific depression prevention intervention is being developed in order to enhance the Guia. This intervention is based on promotion of pleasant activities, self-monitoring of moodstates, and self-monitoring of cigarette consumption. An audiotape with relaxation techniques and a simple narration

will be available to smokers participating in this phase of the study. Pretesting of this intervention has been completed and it will be implemented and evaluated with a cohort of current smokers interested in quitting. Lessons Learned Promotion of smoking prevention and cessation among Latino populations in the U.$. uses overall strategies similar to those that are effective with the majority population. The public health approach supports a population-based intervention that utilizes established channels and social networks. Minimal interventions such as a self-help guide, public service announcements, or a fiveminute counseling session by a trained health care professional are more likely to reach a greater proportion of cigarette smokers than traditional labor-intensive cessation groups or specialized individual treatments. These minimal interventions can be successfully developed to incorporate cultural factors that are characteristic of Latino populations. The background research comparing differences and similarities in knowledge, attitudes, beliefs, and behavior related to cigarette smoking was an essential first step prior to developing the Profframa interventions. We strongly recommend that results from similar types of background research help guide what the content of a specific intervention will include. The production of the Guia Para Dejar de Furaar as the principal cessation intervention gave the Programa a product that could be promoted. As a result of distribution of the Guia, routine contact with several dozen community commercial sites became part of the Programa activities. The electronic media campaign has also heavily promoted the Guia in the PSAs. The popularity of Spanish-language radio and its relatively low cost makes this an important channel through which to reach less acculturated Latinos. Regardless, the impact of television remained impressive and gave the Programa its most widespread

recognition. There is a need to identify innovative approaches to,. reach Latino men with smoking cessation interventions, and the quit smoking contest has been somewhat successful in this regard. The potential of structured telephone consultas and of the role that physicians could play have not been fully developed in the Programa. Webelieve it is essential to develop educational materials that are culturally appropriate using Latino models and situations in photographs, videos, and other visual aids. The health promotion and disease prevention materials should be written in Spanish first, then translated into English, back translated into Spanish, and finally the 6a’6~ two versions should be reconciled. By first developing materials and pretesting these in Spanish, awkward translations from English-language materials are avoided. Materials that are to be used by more than one Latino subgroup need to use universal or "broadcast" Spanish in order to avoid strict regional preferences for idiomatic expressions. In addition, specific approaches that are more effective with Latinos may become evident during the development and pretesting process. Less acculturated Latinos are less knowledgeable about risk factors and how to initiate behavioral changes to prevent cardiovascular disease,6~ and thus they have the most to gain from culturally-appropriate inte~wentions. Policy changes that regulate smoking in the workplace, promotion and sale of cigarettes to minors, and the price of cigarettes may have a greater impact on smoking behavior than any other activity. Improvement in risk factor profile amongLatinos will require leadership from"the Latino community. Scientists, policy makers, community activists, and health care professionals need to collaborate, and Latinos must have a prominent role. Acknowledgements We gratefully acknowledge Fabio Sabogal and Regina Otero-Sabogal for research collaboration and the supervision and implementation of community intervention components; Celina Echazarreta, Francisco Espinoza, Leticia Medina

for their communityoutreach work; Sylvia Correro and Lavinia Espinoza for their administrative support; Programa volunteers and supporters; the Mission Neighborhood Health Center and other collaborating community organizations. Ricardo Munozmade useful comments on an earlier version of this manuscript.

Reference~ 1. U.S. Department of Health and Human Services. Smoking and Health in the Americas. Atlanta, Georgia; U.S. Department of Health and HumanServices, Public Health Service, Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion; DHHSPublication No. (CDC) 928419, 1992; 1-213. 2. Fiore, M., Novomy,T., Pierce,J., Hatziandreu, E., Patel, K~, Davis, R. Trends in cigarette smoking in the United States: The changing influence of gender and race. Journal of the American Medical Association, 1989; 261(1):49-55. 3. Davis, R. Current trends in cigarette advertising and marketiug. NewEngland Journal of Medicine,1987; 316(2):725-732. 4. Tuckson, R. Race, sex, economics and tobacco advertising. Journal of the National Medical Association, 1989; 81:119-1124. 5. U.S. Department of Health and Human Services. Strategies to Control TobaccoUse in the United States: A Blueprint for Public Health Action in the 1990’s. Washington D.C.: Public Health Service, National Institutes of Health, National Cancer Institute; NIH Publication No. 92-3316, 1991:307. 6. Marcus, A., Crane, L. Smoking behavior among U.S. Latinos: An emerging challenge for public health. AmericanJournal of Public Health, 1985; 75:169-172. 7. Igra, A., Stavig, G., Leonard, A. Hypertension and Related Health Problems in California: Results from the 1979 California Hypertension Survey. Sacramento, California: Department of Health and Human Services, 1982. 8. Rogers, R., Crank, J. Ethnic differences in smoking patterns: Findings from NHIS. Public Health Reports, 1988; 103(4):887-393. 9. Stern, M., Rosenthal, M., Haffner, S., Hazuda, H., Franco, L. Sex differences in the effects of sociocultural status on diabetes and cardiovascular risk factors in Mexican Americans: The San Antonio heart study. American Journal of Epidemiology, 1984; 120(6):834-851. 10. Markides, K., CoreiI,J., Ray, L. Smoking among Mexican Americans: A threegeneration study. AmericanJournal of Public Health, 1987; 77:708-711. 11. Remington, P., Forman, M., Gentry, E., Marks, J., Hogelin, G., Trowbridge, F. Current smoking trends in the United States: The 19811983 Behavioral Risk Factors surveys.Journal of the American Medical Association, 1985; 253:2975-2978. 12. Escobedo, L., Remington, P. Birth cohort analysis of prevalence of cigarette smoking amongHispanic in the United States. Journal of the American Medical Association, 1989; 261(1):66-69. 13. Haynes, S., Harvey, C., Montes, H., Nickens, H., Coheu, B. VIII. Patterns of cigarette smoking among Hispanics in the United States: Results from HHANES 1982-1984. American Journal of Public Health, 1990;

July/August1993,Vol. 7, No. 6


80((Suppl)):47-54. 14. Coultas, D., Howard,C., Peake, G., Skipper, B., Samet, J. Discrepancies between selfreported and validated cigarette smoking in a community survey of New Mexico Hispanics. American Review of Respiratory Diseases, 1988; 187:810-814. 15. Centers for Disease Control. Cigarette smoking among black and other minority populations. MMWR, 1987; $6:404-407. 16. Matin, G., Perez-Stable, E., Marin, B. Cigarette smoking among San Francisco Hispanics: The role of acculturation and gender. American Journal of Public Health, 1989; 79:196-199. 17. Perez-Stable, E., Marin, G,. Marin, B. Behavioral risk factors amongLatinos compared to non-Latino whites in San Francisco. American Journal of Public Health, 199B;in press. 18. Pierce,J, Burns, D. California Baseline Survey. San Diego, California: University of California, 1990. 19. Centers for Disease Control. Cigarette smoking among adults-United States, 1990. MMWR, 1992; 41(20):354-362. 20. Padilla, A. Acculturation: Theory, Models and Some New Findings. Boulder, Colorado: Westview Press, 1980. 21. Marin, G., Sabogal, F., Matin, B., OteroSabogal, R., Perez-Stable, E. Development of a short acculturation scale for Hispanics. Hispanic Journal of Behavioral Sciences, 1987; 9:183-205. 22. Cuellar, I., Harris, L.,Jasso, R. An acculturation scale for Mexican-American normal and clinical populations. Hispanic Journal of Behavioral Sciences, 1980; 2:199-217. 23. Szapocznik, J., Scopetta, M., Kurtines, W., Aranalde, M. Theory and measurement of acculturation. Interamerican Journal of Psychology, 1987; 12:113-130. 24. Caetano, R. Acculturation, drinking and social settings among U.S. Hispanics. Drug and Alcohol Dependence, 1987; 19:215-226. 25. Markides, K., Ray, L., Stroup-Benham, C., Trevino, F. Acculturation and alcohol consumption in the Mexican American population of the Southwestern United States: Findings from HHANES1982.84. American Journal of Public Health, 1990; 80(Suppl):42-46. 26. U.S. Department of Health and Human Services. The Health Consequences of Smoking: Nicotine Addiction. Washington, D.C.: U.S. Department of Health and Human Services, Public Health Service, Office on Smoking and Health, DHHSPublication No. (CDC) 88-8406, 1988. 27. Orleans, C., Schoenbach, V., Salmon, M., Strecher, V., Kalsbeek, W., et al. A survey of smoking and quitting patterns among black Americans. American Journal of Public Health, 1989; 79(2):176-181. 28.Jenkins, C., McPhee, S., Bird,J., Ngoc-The, H., Bonilla, B., Thai, V. Cancer risks and prevention behaviors among Vietnamese refugees. Western Journal of Medicine, 1990; 153:34-39. 29. Epidemiology Branch, Office on Smoking and Health, Behavioral Risk Factor Surveillance Branch, Office of Surveillance and Analysis, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control. Cigarette smoking among American Indians and Alaskan nativesBehavioral Risk Factor Surveillance System, 1987-1991. MMWR, 1992; 41(45):861-863. 30. Benowitz, N. the use of biologic fluid samples


American Journal

of Health Promotion

in assessing tobacco smoke consumption. In: Measurement in the Analysis and Treatment of smokingbehavior.J. Grabowski, C. Bell (Eds.). NIDA Research Monograph 48. Washington D.C.: National Institute of Drug Abuse, 1983. $1. Ross, C., Mirowski,J. Socially-desirable responses and acquiescence in a cross-cultural survey of mental health. Journal of Health and Social Behavior, 1984; 25:189-197. 32. Perez-Stable, E., Matin, B., Marin, G., Brody, D., Benowitz, N. Apparent underreporting of cigarette consumption among Mexican American smokers. American Journal of Public Health, 1990; 80(9):1057-1061. 33. Benowitz, N.,Jacob, P., Kozlowski, L., Yu, L. Influence of smoking fewer cigarettes on exposure to tar, nicotine, and carbon monoxide. New England Journal of Medicine, 1986; 315:1310-1313. 34. Shiffman, S., Fisher, L., Zettler.8egal, M., Benowitz, N. Nicotine exposure among nondependent smokers. Archives of General Psychiatry, 1990; 47(4):333-336. 35. Wagenknecht, L., Cutter, G., Haley, N., Sidney, S., Manolio, T., Hughes, G.,Jacobs, D. Racial differences in serum cotinine levels among smokers in the CARDIAstudy. American Journal of Public Health, 1990; 80:1053-1056. 36. Anda, R., Williamson, D., Escobedo, L., Mast, E., Giovino, G., Remington, P. Depression and the dynamics of smoking: A national perspective.Journal of the American Medical Association, 1990; 264(12):1541-1545. 37. Kandel, D., Davies, M. Adult sequelae of adolescent depressive symptmns. Archives of General Psychiatry, 1986; 43:255-262. 38. Glassman, A., Sterner, F., Walsh, B., Raizman, P., Fleiss,J., Cooper, T., Covey, L. Heavy smokers, smoking cessation and clonidine: Results of a double-blind, randomizedtrial. Journal of the American Medical Association, 1988; 259:28632866. 89. Glassman, A., Helzer,J., Covery, L., Cottler, L., Sterner, F., Tipp,J.,Johnson,J. Smoking, smoking cessation, and major depression. Journal of the American Medical Association, 264:1546-1549. 40. Perez-Stable, E., Matin, G., Marin, B., Katz, M. Depressive symptoms and cigarette smoking among Latinos in San Francisco. American Journal of Public Health, 1990; 80( 12): 15001502. 41. U.S. Department of Commerce Economics and Statistics Administration. 1990 Census of Population and Housing. Summarypopulation and housing characteristics, California. Washington, D.C.: U.S. Department of Commerce, 1991. 42. Matin, G., Marin, B., Otero-Sabogal, R., Sabogal, F., Perez-Stable, E. The role of acculturation on the attitudes, norms, and expectancies of Hispanic smokers. Jourual of Cross Cultural Psychology, 1989; 20(4):399-415. 43. Matin, G., Perez-Stable, E., Otero-Sabogal, R., Sabogal, F., Marin, B. Stereotypes of smokers held by Hispanic and white non-Hispanic smokers. International Journal of the Addictions, 1989; 24:203-213. 44. Marin, B., Matin, G., Perez-Stable, E., OteroSabogal, R., Sabogal, F. Cultural differences in attitudes toward smoking: Developing messages using the theory of reasoned action. Journal of Applied Social Psychology, 1990; 20:478-493. 45. Marin, G., Matin, B., Perez-Stable, E., OteroSabogal, R. Cultural differences among Hispanics and non-Hispanic white smokers:

Attitudes and expectancies. Hispanic Journal of Behavioral Sciences, 1990; 12(4):422-436. 46. Matin, B., Perez-Stable, E., Matin, G., Sabogal, F., Otero-Sabogal, R. Attitudes and behaviors of Hispanic smokers: Implications for cessation interventions. Health Education Quarterly, 1990; 17(3):287-297. 47. Sabogal, F., Otero-Sabogal, R., Perez-Stable, E., Marin, B., Marin, G. Perceived self-efficacy to avoid cigarette smoking and addiction: Differences between Hispanics and nonHispanic whites. Hispanic Journal of Behavioral Sciences, 1989; 11(2):136-147. 48. Martin, R., Cummings,S., Coates, T. Ethnicity and smoking: Differences in white, black, Hispanic, and Asian medical patients who smoke. American Journal of Preventive Medicine, 1990; 6(4):194-199. 49. Sabogal, F., Marin, G., Otero-Sabogal, R., Marin, B., Perez.8table, E. Hispanic familism and acculturation: What changes and what doesn’t? Hispanic Journal of Behavioral Sciences, 1987; 9(4):397-412. 50. Triandis, H., Marin, G., Lisansky, J., Betancourt, H. Simpatia as a cultural script of Hispanics. Journal of Personality and Social Psychology, 1984; 47:1363-1375. 51. Fiore, M., Novomy,T., Pierce,J., Giovino, C., Hatziandreu, E., Newcomb,P., Surawicz, T., Davis, R. Methods used to quit smoking in the United States: Do cessation programs help? Journal of the American Medical Association, 1990; 263(20):2760-2765. 52. Glynn, T., Boyd, G., Gruman,J. Essential elements of self-help/minimal intervention strategies for smoking cessation. Health Education Quarterly, 1990; 17(3):329-345. 53. Sabogal, F., Marin, B., Marin, G., OteroSabogal, R., Perez-Stable, E. Guia para Dejar de Fumar. Washington, D.C.: U.S. Department of Health and Human Services, NIH Publication No. 88-3001, 1988. 54.Flay, B. Mass media and smoking cessation: A critical review. American Journal of Public Health, 1987; 77:153-160. 55. Pierce,J., Macaskill, P., Hill, D. Long-term effectiveness of mass media led antismoking campaigns in Australia. American Journal of Public Health, 1990; 80(5):565-569. 56. Perez-Stable, E. Issues in Latino health care. Western Journal of Medicine, 1987; 146:213218. 57. Alcalay, R., Sabogal, F., Marin, G., Perez-Stable, E., Matin, B., Otero~abogal, R. Patterns of mass media use among Hispanic smokers: hnplications for communityinterveutions. International Quarterly of CommunityHealth Education, 1987-1988; 8(4):341-350. 58. Lando, H., Loken, B., Howard-Pitney, B., Pechacek, T. Communityimpact of a localized smoking cessation contest. American Journal of Public Heahh, 1990; 80:601-603. 59. Marin, G., Mariu, B., Perez-Stable, E., Sabogal, F., Otero-Sabogal, R. Chauges in information as a function of a culturally appropriate smoking cessation community intervention for Hispanics. American Journal of Cmnmunity Psychology, 1990; 18(6):847-864. 60. Perez-Stable, E., Sabogal, F., Marin, G., Matin, B., Otero-Sabogal, R. Evaluation of the Guia Para Dejar de Fumar: A Spanish language selfhelp guide to quit smoking. Public Health Reports, 1991; 106(5):564-570. 61. Brislin, R., Lonner, W., Thorndike, E. Crosscultural research methods. NewYork:Johu Wiley & Sons, 1973.

Continued on page 475

The plaintiff experienced coughing and breathing problems and was forced to take a medical leave of absence. It was found that his problems were caused, or severely aggravated, by tobacco smoke. His doctors ordered that he could only return to work in a smoke-free environment. His workers’ compensation claim was denied because the second-hand smokewas not considered a "natural incident" of his employment.The Nevada SupremeCourt explained that an occupational disease must be incidental to the employmentin order to be compensable.It noted, for example, that breathing coal dust was incidental to the work of coal mining. However, the court was unwilling to extend the meaningof occupational disease to include second-handsmoke. It noted, "The legislature, of course, is free to declare that any person who contracts some secondary smoke-related disease at workis eligible for occupational disease compensation. The courts, we believe, do not have this power." (Legal Issues, Corporate Culture) A NewTrial is OrderedWhena Jury Finds Both Smokingand Exposure to Asbestos Werethe Causes of a Shipyard Worker’sLungCancer. Lee v. Pittsburgh Coming Corp., 616 A.2d 1045 (Pa. Super. 1992). A former worker at the Philadelphia Naval Shipyard sued the defendant and other asbestos manufacturers for lung cancer which he alleged resulted from exposure to asbestos. Asbestos had been introduced into the construction of ships during his work years. The medical evidence regarding the cause of the cancer was conflicting. The plaintiff’s medicalexperts testified that his occupational exposure to asbestos caused the cancer. The defendants’ medical experts alleged the cancer was caused by the plaintiff’s smokinghabit. At the trial, the judge instructed the jury that it could find that smokingcaused the cancer (in which case, plaintiff wouldnot recover damages), that the jury could find both caused cancer, and the court would apportion the damagesaccordingly. After the jury found that 60% of the cause was smoking and 40%was exposureto asbestos, the trial court reconsidered its instruction and refused to apportion the damages. The Pennsylvania Superior Court reviewed the trial court’s decision on appeal and ordered a new trial stating, "Assumingthe jury had not been instructed to apportion the causes of harm, it is certainly possible that the appellant (asbestos manufacturer) might have been absolved liability, given the jury’s determination that cigarettes were 60%responsible for (plaintiff’s) cancer." (Legal Issues) In a NewJersey Case, a Trial Judge Instructed the Jury That It Could Find Both Smokingand Exposure to Asbestos WereCauses of a Worker’sLungCancer. Dafter v. RaymarkIndustries, Inc., 611 A.2d136 (N.J. Super. 1992). In a case similar to Lee v. Pittsburgh ComingCorp., a New Jersey shipyard worker suffering from lung cancer sued the manufacturers of asbestos products used in the shipbuilding industry. The evidence regarding the cause of

the cancer was conflicting. The plaintiff’s medical experts claimed the cancer resulted from exposure to asbestos, while the defendants claimed it resulted from cigarette smoking. The jury concluded that the smoking was 70% cause of the cancer, and the asbestos was 30%cause of the cancer. Unlike the Lee case, the trial judge apportioned the damagessuffered by the plaintiff according to the jury’s finding. The NewJersey Superior Court affirmed the trial court’s apportionmentstating that it was within the province of the jury to find that both smokingand exposure to asbestos caused the cancer, and it was also within the authority of the court to apportion damages accordingly. (Legal Issues) AnAll-female Exercise Facility is Permittedto Exclude MalesfromIts Membership. Living’well v. Pennsylvania HumanRelzztions Comm., 606 A.2d 1287 (Pa. Commw. 1992). In a recent case, the Pennsylvania Commonwealth Court considered whether womenenjoyed a "privacy right" which permitted an all-women’s exercise club to exclude men from its membership. Whenthat membership policy was challenged, the state HumanRelations Commissionruled that such an exclusion violated state civil rights. However,whenthe club appealed, the court reversed the decision and found that the female members did have a "privacy" interest which should be protected. The evidence disclosed that the primary reason that many womenjoined the all-female club was the exclusion of males. Manyof the membersnoted their sensitivity to being observed by males while exercising and the embarrassment, anxiety, and stress they wouldsuffer if males were admitted. The court used a three-part test (ordinarily applied to privacy issues in employmentcases) to reach its decision~. First, the club wasable to establish that admitting males would undermine its business or cause membersto quit. Second, the court found the womendid have a legitimate privacy interest which should be protected. Third, there were alternative facilities available to males whowished to exercise in a coed setting. (Legal Issues, Exercise)

SmokingControl Continuedfrom page 442 62. Marin, G., Marin, B. Researchwith Hispanic Populations. NewburyPark, California: SagePublications, 1991;130. 63. Vega,W., Sallis, J., Patterson,T., Rupp,J.,Atkins, C., Nader,P. Assessing knowledge of cardiovascularhealth-related diet and exercise behaviorsin Anglo-and Mexican-Americans. Preventive Medicine, 1987; 16:696-709.

July/August 1993, Vol. 7, No. 6


Lihat lebih banyak...


Copyright © 2017 DADOSPDF Inc.