Tobacco Use and Interest in Smoking Cessation Among Latinos Attending Community Health Fairs
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- Paula Cupertino, A., Cox, L.S., Garrett, S. et al. J Immigrant Minority Health (2011) 13: 719. doi:10.1007/s10903-010-9404-y
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Health fairs are vital for reaching underserved Latinos providing access to health services including smoking cessation. The purpose of this study is to describe tobacco use and interest in smoking cessation among Latino smokers attending community health fairs. We surveyed 262 self-identified Latinos attending health fairs; we assessed smoking behavior and attitudes of 53 (20.2%) current smokers. Smokers were mostly uninsured (98.1%), male (54.7%), recent immigrants (96.2%) with limited English proficiency (60.4% spoke Spanish at home), and were mainly light (86.3%) and nondaily (58.7%) smokers. Although most participants attempted to quit smoking at least once in the past year, only 5.0% of current smokers reported ever using cessation medication and 94.3% were unaware of free-telephone counseling. The majority of smokers were ready to quit within 30 days and were interested in participating in cessation programs. Health fairs provide a unique opportunity to address smoking cessation among underserved Latinos with limited knowledge of access to, and use of effective cessation services.
KeywordsTobacco useSmoking cessationCommunity health fairLatinos
Tobacco dependence treatment for the general population has been rigorously evaluated by the United States Public Health Service USPHS Clinical Practice Guideline for Treating Tobacco Use and Dependence . The USPHS Clinical Practice Guideline recommends that primary care physicians apply a five-step treatment model described as the “5-As”: (1) ask about tobacco use at every visit, (2) advise smokers to quit, (3) assess smokers’ readiness and willingness to quit, (4) assist quit attempts through referral to community services, counseling and pharmacotherapy, and (5) arrange follow-up to prevent relapse . The USPHS Clinical Practice Guideline calls for treatment of all smokers, and recognizes the need for attention to smokers from racial and ethnic minority populations.
Initial progress has been made over the past 15 years in addressing Latino tobacco use . Pérez-Stable and colleagues developed a culturally tailored Spanish-language smoking cessation guide which has been evaluated and effectively used within community interventions targeting low acculturated Latino smokers [4, 5]. One study in particular showed that computerized decision aids are feasible and can facilitate the use of effective treatments for smoking cessation among underserved smokers in the context of health fairs . Few randomized trials have evaluated pharmacotherapy for Latino smokers, although one study demonstrated a doubling in quit rates for smokers who used nicotine replacement compared to placebo . While evidence supports tobacco treatment intervention, Latinos are less likely than white non-Hispanics to participate in smoking cessation programs or to receive advice about stopping smoking from their healthcare providers [8, 9] Furthermore, the rise of the uninsured and the growing number of Latino immigrants without access to primary care limit the reach of the USPHS Clinical Practice Guideline, which focus on interventions through primary care [8, 10, 11]. Given that tobacco use remains the leading preventable cause of disease and death for Latinos and the United States (US) population overall, culturally-sensitive interventions and innovative strategies are urgently needed to reach Latino smokers [12, 13].
Community-based participatory approaches have been successfully implemented in Latino communities to promote cancer awareness, health education and screening, evaluating and treating nicotine dependence and promoting other health behaviors [4, 5, 14–17]. Among community-based programs, health fairs have become a vital source for reaching medically underserved Latinos, providing access to health education, basic needed services, screening, and resource referral [18–20]. Health fair advantages include low costs and high penetration in hard to reach low-income uninsured groups that can benefit the most from strategies to promote health and prevent illness [19, 21–30]. For example, Mexican consulates located across 42 states in the US are actively promoting community health fairs under the Binational Health Week in order to provide health education, access to health services, and referral to community resources for Latino immigrants. Cooperation between health fairs, community organizations, safety-net clinics, Mexican consulates, and academic organizations may fill a fraction of the gap in the healthcare needs of many Latino immigrant communities, and may be used to further our understanding about the health needs of minority groups [6, 26, 28, 29].
While the literature exploring tobacco use among Latinos is increasing, few studies have used community health fairs as an avenue for better understanding tobacco-related disparities among low-acculturated, uninsured Latino smokers. The objective of this study is to describe tobacco use, previous experiences with smoking cessation, and interest in participating in smoking cessation interventions among Latino smokers attending community health fairs. The purpose of this paper is to describe the potential for using health fairs to extend the reach of effective evidence-based smoking cessation interventions. This strategy is most consistent with the ‘Reach’ component of the RE-AIM model that evaluates the translation of effective interventions into practice [31–33]. This information is crucial to increase our knowledge about smoking behaviors and attitudes among Latino immigrants, with the goal of enhancing the reach and success of future smoking cessation interventions.
Researchers from the Department of Preventive Medicine and Public Health at the University of Kansas Medical Center (KUMC), organizational representatives and members of the Kansas City area Latino community formed a partnership known as the “Latino Health Initiatives Network (LHIN)”. The network goals are to promote health equity and eliminate health disparities among US Latinos. For the past 5 years, as part of this partnership we have implemented several health events including community health fairs in areas with a predominantly Latino population (see list of partners in the acknowledgments). As part of two health fairs, we surveyed participants to improve our understanding of their smoking and cessation behaviors. This study was approved by the University of Kansas Medical Center Institutional Review Board.
Bilingual surveyors were recruited through the Latino Health Initiative Network’s contacts. They participated in a culturally relevant 2 h training session which equipped them with the knowledge and skills to conduct surveys at a large health fair. A facilitator reviewed, in detail, all survey items with the surveyors in order to clarify questions. Surveyors then role-played the procedures and received feedback from the facilitator. All surveyors completed the KUMC Human Subjects Protection and Research Requirements tutorial.
This study was conducted within two community health fairs in Kansas City. Throughout the health fairs, six bilingual surveyors were strategically placed at different screening areas to identify potential participants. At each health fair, each surveyor completed approximately 15–25 surveys between 9 a.m. and 2 p.m. Surveyors approached adults while they were waiting in line to complete their screenings and were invited to participate in the study. Eligibility criteria included self-identified Latinos 18 years or older. Consent for participation was reviewed in individuals’ language of preference (Spanish or English). Participants who provided oral consent completed a 15 min survey in participants’ language of choice (Spanish or English). Out of the 1,032 individuals attending both community health fairs, we identified a convenience sample of 262 self-identified Latino males and females 18 years or older. The present study will report on participants that were current smokers.
Assessment of socio-demographic data included age, gender, race, ethnicity, country of origin, education and employment status, household income, health insurance access, and language preference. For participants born outside the US, we assessed length of time living in the United States and in the state of Kansas. Recent immigrants were defined as those who migrated to the US within the last 10 years. In this study, we also assessed whether or not individuals had received a general check up with a doctor within in the previous year (i.e. not an exam for a specific injury, illness, or condition).
Current smokers were defined as those who had smoked more than 100 cigarettes in a lifetime and had smoked (even a puff) in the past 30 days. Former smokers were defined as 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, and time to first cigarette of the day after waking. Among current smokers, we considered daily smokers as those who smoked 25 or more days in the past month, and light smokers were those who reported an average of 10 or fewer cigarettes per day (cpd).
Assessment of previous smoking cessation behaviors included number of previous quit attempts, cessation treatments used in the past, thoughts about quitting, reasons for quitting, and interest in participating in a smoking cessation program in the future.
Simple frequencies for demographic variables for all smokers were calculated with means and standard deviations describing the number of cigarettes smoked per day, the number of days smoked per month, smoking cessation behavior, and interest in quitting. All analyses were performed using 17.0 SPSS statistical software.
Out of the 270 individuals completing the survey, 262 (97.0%) were self-identified Latinos of whom 14 (5.3%) were former smokers and 53 (20.2%) were current smokers. Among these 53 smokers, the mean age was 37.1 years (SD = 9.3). Approximately two-thirds of current smokers were male (54.7%), had high school education or less (67.9%), and were employed (62.1%). Approximately half of smokers reported an estimated annual household income of less than or equal to $20,000 (47.2%). Most were immigrants (only 3.8% born in the US), from Mexico (79.5%). There were 8 different Latin American countries represented in the sample: Argentina, Colombia, Ecuador, El Salvador, Guatemala, Honduras, Mexico, and Uruguay. The majority spoke only Spanish at home (60.4%), and had lived in the US for an average of 10.4 years (SD = 8.1) and an average of 7.7 years in Kansas (SD = 6.4). Very few smokers had health insurance (1.9%), relying on health fairs and community health safety-net clinics to access healthcare services. Among smokers who reported having visited a doctor for a general or physical exam, 17.2% had a check up less than a year ago, 58.6% had a check up more than a year ago. Overall, 20.7% had never had a doctor visit in the past.
Smoking characteristics and interest in quitting among current latino smokers attending health fairs
Cigarettes per day (cpd), M ± SD
6.0 ± 7.0
Light smokers (cpd ≤10)
Days smoked/month, M ± SD
17.9 ± 12.1
First cigarette of the day, n (%)
within 5 min
within 6–30 min
within 31–60 min
after 60 min
Previous quit attempts, n (%)
0 quit attempts
1–2 quit attempts
3–8 quit attempts
9 or more quit attempts
Stopped smoking for at least 24 h in past year, n (%)
Previous quitting methods used, n (%)
“Cold turkey” strategy/willpower/no special method
Nicotine replacement therapy (NRT)
Pill, counseling, medical advice, books or tapes, quitline, or Internet-based support
Thinking about quitting, n (%)
within 30 days
within 6 months
not thinking about quitting within the next 6 months
Reasons for quitting, n (%)
Interest in smoking cessation program, n (%)
Would definitely participate in free program
Would probably/might participate in free program
Would not participate
Findings suggest that 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. Latino smokers attending these health fairs were most likely to be recent male immigrants with limited English proficiency, limited access to health care providers and smoking cessation programs. The current study also found that Latino smokers attending community health fairs have previously tried to quit smoking, are interested in stopping smoking and in receiving smoking cessation treatment.
The USPHS Clinical Practice Guideline for Treating Nicotine Dependence recommends that all smokers be offered evidence-based treatment . Nonetheless, there are several barriers to fully implementing the USPHS Clinical Practice Guideline, and the utilization of both pharmacotherapy and counseling remain low among underserved minority groups, as found in this study. Lack of knowledge about available smoking cessation resources , and the lack of access to smoking cessation treatments may prevent Latinos from quitting. In this study, the majority of participants had made quit attempts without using evidence-based cessation resources. Health fairs may represent a unique opportunity to reach this underserved group with limited access to clinic-based smoking cessation interventions. Future health fairs could further increase utilization of smoking cessation resources by adding more information on pharmacotherapy and smoking cessation quitline referrals. Joining forces with pharmaceutical assistance programs could also significantly improve access to cessation medications. In sum, health fairs could further the reach of effective smoking cessation interventions by providing many of the USPHS Clinical Practice Guideline for Treating Nicotine Dependence interventions including the “5-As” cessation services to smokers.
A study by Foraker  assessing beliefs and attitudes regarding tobacco use interventions among young adult Latinos established that cultural attitudes towards tobacco use and perceived barriers to quitting must be recognized when developing culturally appropriate smoking cessation interventions for Latinos. In our present study, in addition to health concerns, family was identified as a prominent reason for quitting smoking. These findings could be related to the cultural value of “familismo”. “Familismo” is guided by the principles of commitment, loyalty, and obligation to family and influence health-related decision making and subsequent health behaviors . Future studies should further explore the role of Latino family values in quitting smoking in order to be more culturally acceptable and effective among the Latino population.
Nationwide, there are approximately 45.7 million uninsured individuals . Among Latino adults living in the United States who are not legal permanent residents, approximately 60% lack health insurance, compared to 28% of Latino legal permanent residents or citizens . Consistent with these data, 98.1% of our study’s participants reported not having health insurance. Community health fairs may be the only opportunity for these individuals to access smoking cessation resources. Additionally, these health fairs reached a younger population, including a greater proportion of males than commonly seen in community clinics and other health care venues .
Most smokers in this study are light smokers and non-daily smokers. This finding is consistent with other Latino studies and highlights the need to address tobacco use treatment to full range of tobacco use [1, 3, 4, 38, 39]. Given the higher prevalence of light smoking among Latino and other racial and ethnic minority populations and the growing prevalence of light smoking in the general population, further research is needed on treating light smokers as recommended within the USPHS Clinical Practice Guideline .
This study has several limitations that should be considered. Participants in this study were primarily Spanish-speaking immigrants identified within health fairs that largely served low-income, uninsured recent immigrant Latino smokers. Thus, our findings apply primarily to this underserved population and are not representative of all Latinos. Secondly, interest in different types of cessation treatments was not assessed within this study yet should be collected to inform future studies. Thirdly, the small sample size of Latino smokers hinders the analysis of differences across acculturation levels and gender. Even so, this study makes a unique contribution by reporting on the role of community health fairs to identify smokers and further inform them about culturally appropriate smoking cessation programs.
Findings support the feasibility of using community health fairs to promote tobacco use treatment for underserved and uninsured Latinos. Latino smokers have a high interest in quitting smoking and participating in free smoking cessation programs but limited knowledge of existing community resources. Health fairs could provide smoking cessation education and refer smokers to existing treatment resources, including state-funded telephone quitlines. In order to enhance Latino smoking cessation, future studies are needed to identify how to best apply culturally appropriate and evidence-based treatments within the context of community health fairs.
This study was conducted by the Latino Health Initiative Network (LHIN) in collaboration with Maria Reyes and Cielo Fernandez (El Centro, Inc.), Brooke Groneman (Kansas University Cancer Center), Paula Cupertino, Susan Garrett and Irazema Mendoza (Department of Preventive Medicine and Public Health at the University of Kansas Medical Center), Francesca Beard (Coalition of Hispanic Women Against Cancer), Toyin Sokari (National Cancer Institute’s Cancer Information Service), Jorge Coromac and Florence Ndikum-Moffor (Heart to Heart International) and Gabriela Flores (Truman Medical Centers). This study was supported in part by funding from the Healthcare Foundation of Greater Kansas City. We are grateful to the volunteers and community members who participated in this project.