This study examined the relationship between acculturation and knowledge of health harms and benefits of smoking among Latinos in Minnesota. A survey of 804 Latino adults found high knowledge that smoking causes lung cancer and heart disease, though smokers had less knowledge of heart disease risks. More acculturated respondents knew less common health links. Smokers perceived more smoking benefits than non-smokers, and greater acculturation predicted perceiving more benefits. The study used multidimensional acculturation measures to better understand how culture influences beliefs about smoking.

1. Short communication
The relationship between acculturation and knowledge of health harms and benefits
associated with smoking in the Latino population of Minnesota
Melissa L. Constantine a,
⁎, Todd H. Rockwood a
, Barbara A. Schillo b
, Jose William Castellanos c
,
Steven S. Foldes d
, Jessie E. Saul b
a
Division of Health Policy and Management, School of Public Health, University of Minnesota, C312 Mayo Memorial Building, 420 Delaware Street, SE, MMC 729,
Minneapolis, MN 55455, United States
b
ClearWay Minnesota
sm
, Two Appletree Square, 8011 34th Avenue South, Suite 400, Minneapolis, MN 55425, United States
c
Family Centric Health Promotion Program, Communidades Latinas Unidas En Servicio, 720 East Lake Street, Minneapolis, MN 55407, United States
d
Center for Prevention, Blue Cross Blue Shield of Minnesota, St. Paul, MN 64560, United States
a b s t r a c ta r t i c l e i n f o
Keywords:
Smoking
Acculturation
Latino
Health
Knowledge
Beliefs
Objectives: This study sought to examine the relationship between acculturation and the knowledge of
smoking and health and perception of benefits associated with smoking within the Latino population of
Minnesota. In addition to standard acculturation measures, this study employed a multidimensional model
and measures of acculturation.
Methods: A telephone and in-person administered survey was conducted across the state of Minnesota with
Latino men and women.
Results: A total of 804 participants completed the survey, 54% were men. The average age of respondents was
37 years; 81% were foreign born and 68% completed the interview in Spanish. Knowledge of the relationship
between smoking and lung cancer (99%) and heart disease (93%) was high. Acculturated respondents
indicate a more refined knowledge of the relationship between smoking and health conditions not related to
smoking (poor vision and arthritis). Smokers identify more benefits associated with smoking than do non-
smokers, with gender (male), education (less than high school) and greater acculturation being significant
predictors of perceiving benefits.
© 2009 Elsevier Ltd. All rights reserved.
1. Introduction
This paper evaluates knowledge and beliefs regarding the harms
and benefits associated with cigarette smoking in the Latino
population. This is useful because an understanding of these issues,
particularly for immigrants, can inform norms specific to smoking
behavior as well as benefit smoking prevention and cessation efforts
(Waldron et al., 1988; Steptoe et al., 2002).
Nationally, Latinos report lower smoking rates (16.2%) than non-
Latino whites (21.9%) (CDC, 2007), but this is an area of concern due to
the targeted marketing of tobacco products to the Latino community
(CDC, 1998; Laws, Whitman, Bowser, & Krech, 2002; Portugal et al.,
2004). Within the Latino population there is initial evidence that
smoking behavior, knowledge and beliefs about smoking are related
to both gender and acculturation (Bock, Niaura, Neighbors, Carmona-
Barros, & Azam, 2005; Maher et al., 2005; Waldron et al., 1988); as
Latinos become more acculturated their smoking behavior becomes
more similar to that of non-Latino whites. Where smoking rates for
Latino men are similar to rates for non-Latino white men (Maher et al.,
2005), the effect of acculturation translates to an increase in the
number of cigarettes smoked per day (CDC, 2007; Marin, Perez-Stable,
& Marin, 1989). While Latina women are found to have much lower
smoking rates than their non-Latino white counterparts (Maher et al.,
2005), the relationship between acculturation and smoking behavior
is particularly concerning for women (Bock et al., 2005). Findings
suggest significant increases in smoking prevalence within Latina
women as acculturation to U.S. norms increases (Abraido-Lanza, Chao,
& Florez, 2005; Marin et al., 1989; Perez-Stable et al., 2001).
2. Methods
2.1. Sampling design
A community based participatory research model guided the
design and administration of this study. The sample for this study was
a surnamed screened listed frame, in which telephone and face-to-
face interviews were conducted. Eligible participants were individuals
Addictive Behaviors 34 (2009) 980–983
⁎ Corresponding author. Tel.: +1 612 624 9943; fax: +1 612 624 4408.
E-mail address: cons0026@umn.edu (M.L. Constantine).
0306-4603/$ – see front matter © 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.addbeh.2009.05.008
Contents lists available at ScienceDirect
Addictive Behaviors

2. who self identified as Latino or who had a Latino heritage, e.g.
parents/grandparents born in Central or South America.
2.2. Instrument
The survey instrument was translated from English into Spanish
through a community review process, cognitive interviews as well as
principles of translation/back translation. The survey had a 50%
response rate and the total number of completed interviews was 804.
The data were weighted to account for subject's a priori differential
probabilities of selection based on stratum and number of adults living
in the household. The post-stratification weight was applied to the
person weight to match known population distributions by age and
gender of the Latino population in Minnesota based on 2000 Census
data.
2.3. Dependent variables
The outcomes of interest are respondent knowledge of the rela-
tionship between smoking and specific health conditions, and
respondent beliefs about potential benefits of smoking. Respondents
were asked to identify whether the each of the following health
conditions is caused by smoking: lung cancer, heart disease, poor
vision and arthritis. Respondents were asked to indicate whether
smoking helps a person make friends, provides pleasure, relieves
stress and anxiety, helps focus on activities and helps lose weight.
2.4. Independent variables
Standard gender, age, marital status and education demographics
were included. Assessment of smoking status was based on the CDC's
Behavioral Risk Factor Surveillance Survey (BRFSS) definition of
current smoker: have ever smoked a cigarette, have smoked at least
100 cigarettes in their life, and now smoke every day or some days.
Most tobacco use research with immigrant populations has relied
on primary language, years of residence in the US or where born (US
or non-US) as proxies for an indication of level of acculturation (Bock
et al., 2005; Crespo, Smit, Carter-Pokras, & Anderson, 2001; Maher et
al., 2005). As part of this research, a multidimensional conceptualiza-
tion of community was utilized to assess community integration and
acculturation. From this conceptualization two major constructs
emerged: cultural fluency and cultural orientation. Both constructs
are modeled as indicators of community identification; home country
identification and U.S. identification. For this research cultural fluency
is defined as acquired knowledge; cultural skills acquired through
socialization (e.g. language(s), sense of nationality and shared history,
knowledge of traditions, religious and appropriate social behaviors).
Cultural orientation is defined as attitudes and behavior; identifica-
tion with culture of origin and new culture and participation in
community institutions and activities. A total of 17 items were used to
assess this range of issues. These 17 items have been reduced to five
latent variables, two focused on fluency and three on orientation. Of
the two fluency variables, one is focused on US culture and one is
focused on home country1
. Three variables represent different aspects
of cultural orientation; comparison of self to typical white Minneso-
tan, importance of practicing home country ways in the home and
social embedded-ness in Latino community.
3. Analysis
Outcome variables are dichotomized (0,1) for knowledge of each
health condition listed (1=correct identification), and each listed
benefit (1=benefit). Chi-square and t-tests were used for bivariate
comparison of basic socio-demographic characteristics and outcomes,
and multivariate logistic regression is used to model predictors of each
outcome variable. Predictive values of variables are reported as odds
ratios for prediction of correct identification of health condition or
perception of benefit. Data were analyzed using the statistical
software SAS©
9.1 and a significance level of .05 or less is used.
4. Results
4.1. Demographics
The study achieved a 50% response rate (n=805) (AAPOR RR1,
2008). Over half (55%) were in-person interviews. The average age is 37,
54% of respondents are male, 71% of respondents are married and overall
39% of the sample has completed high school. A full 68% of respondents
completed the interview in Spanish and the sample is predominantly
first generation immigrants (81%). The average number of years
immigrants have lived in the US is 13. The overall smoking rate is
13.5%; within males it is 22% and within females it is 4%.
4.2. Knowledge of smoking-related health conditions
Knowledge that smoking causes lung cancer was high, over 99% for
both smokers and non-smokers. Non-smokers (94%) were more likely
to correctly identify smoking as causing heart disease than smokers
(87%). Smokers (62%) were better able to identify arthritis and
smoking as unrelated than non-smokers (43%). Finally, a high
percentage of both non-smokers (78%) and smokers (60%) incorrectly
identify poor vision as being caused by smoking.
4.3. Predictors of knowledge of smoking related health harms
As shown in Table 1, relative to knowledge of smoking as a cause of
heart disease, gender and education are strong predictors, with males
and respondents with less than a high school education much more
likely than females and those with a high school education to know of
this relationship. Knowledge of the role of smoking in heart disease is
negatively associated with smoking; non-smokers are much more
likely than smokers (more than 5 times more likely), to correctly
1
For immigrants this refers to the country they immigrated from. For Latinos born in
the US this refers to the country their parents or grandparents immigrated from or in
the case of multiple generations in the US Latino Culture.
Table 1
Multivariate logistic regression of factors associated with the identification of risks
associated with smoking (Odds ratio, 95% Wald confidence limit).
Lung
cancer
Heart disease Poor vision Arthritis
Smoking status 0.19
(0.09–0.41)⁎⁎⁎
2.55
(1.59–4.07)⁎⁎⁎
2.48
(1.55–3.98)⁎⁎⁎
Gender 0.22
(0.11–0.44)⁎⁎⁎
Age
Marital
Education 0.44
(0.22–0.86)⁎
2.16
(1.43–3.27)⁎⁎⁎
1.50
(1.07–2.10)⁎
Language
US born 2.79
(1.81–4.31)⁎⁎⁎
5.37
(3.27–8.83)⁎⁎⁎
Fluency with US culture
Fluency with home
country culture
Comparison to Minnesotan 1.26
(1.04–1.53)⁎
Importance of home
country ways
1.96
(1.52–2.53) ⁎⁎⁎
0.84
(0.71–1.00)⁎
Social network 0.74
(0.61–0.89)⁎⁎
Binary variables are dummy coded (0,1) with referent non-smoker, male, not married,
less than HS education, English interview and born in US.
⁎pb0.05, ⁎⁎pb0.01, ⁎⁎⁎pb0.001.
981M.L. Constantine et al. / Addictive Behaviors 34 (2009) 980–983

3. identify smoking as a cause of heart disease, an indication that this
knowledge may be protective. The only acculturation measure that is
significant as a predictor of correctly identifying smoking as a cause of
heart disease is the importance of practicing home country ways in
the home, almost two times more likely to identify the role of smoking
in heart disease.
Smokers and respondents with at least a high school education are
more likely to know poor vision and arthritis are not considered to be
caused by smoking. Relative to acculturation measures as predictors,
respondents who are born in the US and respondents who are less
socially embedded in the Latino community are more likely to know
that poor vision and arthritis are not caused by smoking.
4.4. Perception of benefits of smoking
There is a significant difference between smokers and non-
smokers identification of benefits to smoking in three areas, with
smokers identifying more benefits than non-smokers; smoking
provides pleasure (42%/21%), relieves stress and anxiety (57%/24%),
and helps focus on activities (16%/10%).
4.5. Predictors of perception of benefits of smoking
Smokers are almost 3 times more likely than non-smokers to see
smoking as providing pleasure and over 4 times more likely than non-
smokers to see smoking as relieving stress and anxiety (Table 2).
Males are twice as likely as females to identify smoking as helping to
make friends and improving ability to focus. Older respondents are
more likely to identify pleasure and weight loss as benefits than
younger respondents, but the effect size is small. Respondents who
are not married are more likely than married respondents to identify
weight loss and ability to focus as benefits of smoking. Respondents
with a high school education or more are twice as likely to think
smoking provides pleasure and relieves stress.
Respondents who are more fluent with US culture are more likely to
identify benefits (pleasure and stress relief) of smoking, whereas
respondents who are more fluent with their home country culture
identify improved ability to focus as a benefit. Respondents who are less
likely to feel they are similar to typical white Minnesotans are also more
likely to see smoking as providing pleasure and relieving stress although
they are less likely to believe smoking improves ability to focus. Other
indicators primary language or where born were not predictive.
5. Discussion
A major contribution of the current research is the use of more
refined measures of acculturation. While the measures confirm prior
research, it should be noted that the primary indicators (primary
language, where born, years in US) were not predictive, but the latent
variables did detect differences due to level of acculturation. This
study illustrates that specific socio-cultural factors are important to
understanding beliefs relative to the harms and benefits of smoking in
the Latino population.
It has to be pointed out that the distribution of key indicators (place
of birth, primary language, length of time living in the US) in this study
compared to others is skewed towards a population that is oriented
towards home country orientation. This may be supported by the low
smoking rate for females (4%) as compared to rates found by other
studies in a more acculturated population (11.1%) (CDC, 2006), which
could be seen as support for the finding that as “Americanization”
occurs in Latina women the smoking rate increases.
Generally, smokers demonstrate a more refined knowledge of the
relationship between smoking and health than non-smokers. This may be
attributable to the salience to smokers of the relationship between health
and smoking behavior, or it may also be an indicator of a perception
within the Latino population, and particularly less acculturated Latinos, of
smoking as a behavior that is overall detrimental to most aspects of
health. While general population studies find that smokers are as know-
ledgeable or more knowledgeable than non-smokers relative to the
relationship between smoking and heart disease (Weinstein, Slovic,
Waters, & Gibson, 2004), the finding of this study that Latino smokers are
so much less likely than Latino non-smokers to understand the role of
smoking in heart disease is troubling, particularly as coronary artery
disease is the leading cause of death for Latinos in the U.S. (USDHHS,
1998).
Differences between gender and level of acculturation relative to
beliefs about the health effects of smoking as well as perceived benefits
of smoking are both related to actual smoking behavior. This knowledge
may help guide future community education efforts within the Latino
population. The finding that smokers are less aware of the link between
smoking and heart disease than non-smokers indicates a need to
increase educational efforts around this issue for Latinos.
The gender differences relative to smoking and making friends and
improving ability to focus is not surprising given the cultural stigma
attached to women smoking in many Latino cultures. Based on our
findings from earlier work in the Latino community, smoking is con-
sidered a very social activity among male peers. Therefore, greater
orientation towards home country culture and social integration within
the community and may serve to reinforce smoking behavior among
Latino men. The stigma associated with smoking for women is reflected in
the differences of perception of benefits between men and women.
Cessation programs should provide services for individuals or for groups
of women alone, but not necessarily for mixed groups of men and women.
Acknowledgments
Funding for this project was provided by ClearWay MinnesotaSM
(RC 2005_0019). The contents of this manuscript are solely the
Table 2
Multivariate logistic regression of factors associated with the perceived benefits of smoking (Odds ratio, 95% Wald confidence limit).
Make friends Pleasure Relieve stress/anxiety Focus Weight loss
Smoke status 2.72 (1.75–4.22)⁎⁎⁎ 4.36 (2.83–6.73)⁎⁎⁎
Gender 0.51 (0.31–0.85)⁎⁎⁎ 0.35 (0.21–0.60)⁎⁎⁎
Age 1.02 (1.00–1.03)⁎ 1.03 (1.02–1.05)⁎⁎⁎
Marital 0.55 (0.34–0.88)⁎ 0.58 (0.41–0.82)⁎⁎
Education 2.17 (1.46–3.22)⁎⁎⁎ 2.10 (1.44–3.05)⁎⁎⁎
Language
US born
Fluency with US culture 0.63 (0.51–0.78)⁎⁎⁎ 0.61 (0.50–0.75)⁎⁎⁎
Fluency with home country culture 1.40 (1.07–1.84)⁎
Comparison to Minnesotan 1.26 (1.04–1.53)⁎ 1.30 (1.08–1.57)⁎⁎ 0.72 (0.58–0.91)⁎⁎
Importance of home country ways
Socially embedded
Binary variables are dummy coded (0,1) with referent non-smoker, male, not married, less than HS education, English interview and born in US.
⁎pb0.05, ⁎⁎pb0.01, ⁎⁎⁎pb0.001.
982 M.L. Constantine et al. / Addictive Behaviors 34 (2009) 980–983

4. responsibility of the authors and do not necessarily represent the
official views of ClearWay Minnesota.
Appendix A
Fluency 1 Scale Fluency with U.S. culture
How well do you understand the Boston tea party?
How well do you understand the legend of Paul Bunyan and babe
the blue ox?
How well do you understand U.S. sporting events such as the Super
Bowl or Stanley Cup playoffs?
How well do you understand U.S. Holidays such as thanksgiving
and 4th of July?
Fluency 2 Scale Fluency with home country culture
If you attended a wedding or funeral based on bfillN traditions, how
well would you understand what is going on?
I understand bfillN traditions very well
Orientation 1 Scale Comparison of self to a “typical white Minnesotan”
for behaviors
Comparing yourself to a typical white Minnesotan, how similar or
different are you in terms of the music you listen to?
Comparing yourself to a typical white Minnesotan, how similar or
different are you in terms of the expressions you use when you
speak (slang)?
Comparing yourself to a typical white Minnesotan, how similar or
different are you in terms of the food you eat?
Comparing yourself to a typical white Minnesotan, how similar or
different are you in terms of the sports or sporting teams you follow?
Orientation 2 Scale Importance of maintaining home country ways in
home
How important do you feel it is to keep in touch with or learn about
your fill ethnic or cultural background?
How important is it to you that bfillN ways are practiced in your
home?
Do you think you are similar or different to people who live in bfillN
(country)
How strongly do you identify with your fill background?
Orientation 3 Scale Ethnicity of Social Network
How many of your close friends are from the same ethnic background
as you?
How many of your casual friends or acquaintances are from the
same ethnic background as you?
How many of your neighbors are from the same ethnic background
as you?
All are scored so that a low score indicates US and a high score
indicators home country.
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