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					 Smoking among Latino Immigrants:
       Developing Solutions

          Susan Garrett
           Project 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 Kansas
                                                1990                           2007
                                Number                   Percent    Number            Percent
 Total Population of           2,477,574                  100.0    2,775,997           100.0
       Kansas1
     Native born               2,414,734                   97.5    2,608,912            94.0
     Foreign born               62,840                      2.5     167,085             6.0
    Foreign-Born                60,854                    100.0     167,085            100.0
Population of Kansas2
   Born in Europe                13,113                   21.5      13,502             8.1
    Born in Asia                 23,952                   39.4      45,080             27.0
    Born in Africa               1,232                     2.0       9,511             5.7
  Born in Oceania                 511                      0.8        202              0.1
Born in Latin America            19,398                   31.9      95,897             57.4
  Born in Northern               2,648                     4.4       2,893             1.7
      America




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
                     Percent
PERIOD OF ENTRY BY WORLD REGION OF BIRTH -
2007
Born in Mexico           100.0
Entered in 2000 or after 37.7
Entered 1990 to 1999     35.7
Entered 1980 to 1989     16.1
Entered before 1980      10.4
CITIZENSHIP STATUS BY PERIOD OF ENTRY
Total Foreign-Born Population
Not a citizen             68.8
Naturalized citizen       31.2
GENDER
Total Native-Born Population
Male                      49.2
Female                    50.8
Total Foreign-Born Population
Male                      53.1
Female                    46.9
MARITAL STATUS
Total Native-Born Population
Now married (not separated)              54.1
Separated                                1.3
Divorced                                 11.5
Total Foreign-Born Population
Now married (not separated)              62.8
Separated                                3.0
Divorced                                 6.2
HOUSEHOLD AND FAMILY SIZE
Total Native-Born Population
Average family size                      2.98
Total Foreign-Born Population
Average family size                      3.57
FERTILITY
Total Native-Born Female Population, Ages 15 to 50
Women who had a birth -last 12 months    6.3
 Married                                 4.4
Total Foreign-Born Female Population, Ages 15 to 50
Women who had a birth - last 12 months   10.9
 Married                                 9.8
                                                     Age Distribution                                                     Population Pyramid of Hispanic Population - Johnson and Wyandotte County, 2006
                     Population Pyramid -State of Kansas 2006

85 and up
 80 to 84
                                                                                                       80 to 84
 75 to 79
 70 to 74
 65 to 69                                                                                              70 to 74
 60 to 64
 55 to 59
                                                                                                       60 to 64
 50 to 54
 45 to 49
 40 to 44                                                                                              50 to 54
 35 to 39
 30 to 34
                                                                                                       40 to 44
 25 to 29
 20 to 24
 15 to 19                                                                                              30 to 34
 10 to 14
    5 to 9                                                                                             20 to 24
    0 to 4

             6   4      2                        0               2                 4               6
                                                                                                       10 to 14

                                Percentage of Total Population
                                                                                                         0 to 4
                                                                     Sex: Female       Sex: Male

                                                                                                                  8   6           4                2                  0                  2           4     6   8
                                                                                                                                                        Percentage of Total Population


                                                                                                                                                            Sex: Female    Sex: Male
Geographic Location and
Dispersion of Immigrants
    United States Race/Ethnicity Projections
                   2010‐2050
                (by percentage)
        2000     2010 2020     2030   2040   2050

HISPANIC 12.6    15.5   17.8   20.1   22.3    24.4

WHITE    81.00   79.3   77.6   75.8   73.9   72.1


BLACK    12.70   13.1   13.5   13.9   14.3   14.6


ASIAN     3.8     4.6    5.4   6.2    7.1    8.0

ALL
          2.5     3.0    3.5   4.1    4.7    5.3
OTHER
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 Kansas
Counties with Same or Higher Pct. of Hispanic Population compared to Wyandotte Co.
                             (2005 Census Estimates)


                                                                            21.4%



                                                                   8.4%




               41.5%
 25.6% 27.8%

                       45.7%                    9.9%
 30.3% 37.6% 26.6%


       26.4% 49.5%
Health and Latinos in
 Wyandotte County
         Hispanic Birth Rates
        Wyandotte County, KS
• Hispanic birth rate
  26.9 per 1,000 population

• Non-Hispanic birth rate
  16.5 per 1,000 population
         HOSPITAL DIAGNOSIS STATISTICS
       COMPLICATONS DURING PREGNANCY
   • Complications of pregnancy, childbirth &
     puerperium

                 Hispanic – 243.7 per 10,000
                 Non-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
                                                            Pct. Uninsured
Race/Ethnicity                                     Under Age 65        Children Under Age 19
Hispanic                                                  31.7                                   30.2
White Non-Hispanic                                        11.9                                   10.0
Black                                                     16.8                                    8.7
Note: Uninsured figures are for Region 1 in Kansas which included Wyandotte and Leavenworth Counties.

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


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              23.5          20.6
  African Am         25.6          17.8
  Latino             20.7          10.7
  Asian              15.7           4.7
  Am Indian          42.3          22.4
  8 years or less    24.2           13.0
  9-11 yrs school    38.1           33.6
  high school dipl   30.0           21.5
  College degree     11.5            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)        25.7      10.3
2 to <3               25.0      11.9
3 to <5 (more)        23.0      15.5
   Light and Non-Daily Smokers
Tobacco Use Supplement CPS, 2003
             % Current         % Non-
                              Daily / 1-5
                                 cpd
White          24.5             17/ 5
African Am     20.3             24/12
Latino         14.2             35/18
Asian/PI       12.3             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.
TWO SAFETY NET CLINICS                       Methods
   Identify Smokers

                                           3. Personalized
                                           Health Education
                         1. Quitline
                         Referral

                         2. Provider
                         Summary


                         Provider                 Patient

                                       Outcomes
              Outcome Measures
Recruitment         Kiosk Utilization              2 mo FU




                                            Utilization of
                                            Smoking Cessation
                                            Resources



Previous Use of         Interest in Using
Smoking Cessation       Smoking Cessation
Resources               Resources
          163 Referred to Kiosk




                                                      35 (21.5%) Refused




    128 (78.5%) Consented and Completed the Kiosk



                                                      39 (30.5%) Lost to
                                                          Follow-Up




89 (69.5%) Completed Two-Month Follow-Up Assessment
STRENGTHS                                                  WEAKNESSES
Counseling from Providers
“Pretty impressed. The doctor had mentioned to me          “Call participants about once a week to check on
before to quit smoking, but this time was different. The   them. Might be annoying to some people, but some
way she sat me down at the computer and everything         people would find it helpful. Maybe make that an
was good.”                                                 option. Feed this info back to my doctor, she knows
“The patient being able to talk with a doctor.”            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         “Make Chantix available for those who can't afford
smoking.”                                                  it. If my doctor hadn't given me a voucher for it I
“Finding out what kind of medications are available.”      wouldn't be doing so well. I really, really like
                                                           Chantix and it has helped me a lot.”
“I think being able to choose the different meds.”
                                                           “Maybe use over-the-counter medication, not
                                                           prescription.”
Kiosk utilization
“I liked the computer being at the doctor's office.”       “Letting people input their own information. For
“That it was in our language and that other people         example, in my case being able to explain the
cared about our health.”                                   adverse effects the medications have on me and
                                                           either having somebody call me back or get that
“Made to be convenient. The way the kiosk was set up       information to my doctor.”
was easy to use. Made it easy for the providers to help
the patient. I'm glad the program offered free          “Mention the great American smoke out and its
medication otherwise I would not have had the           significance. Show picture of smoker lung versus a
resources to do this myself.”                           non smoker lung.”
Quitline Utilization
“The attention I received by the people especially the “I'm not satisfied, I never received a phone call from
telephone counselors.”                                 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 training
Topic                                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 activities
                              ACTIVITIES                                 #
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!

				
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