Smoking among Latino Immigrants: Developing Solutions

1. Smoking among Latino Immigrants: Developing Solutions Susan Garrett Project Director Paula Cupertino, Ph.D. Assistant Professor Preventive Medicine & Public Health November 10, 2010

2. 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

3. Immigrant Population in Kansas

4. Immigrant Population in Kansas The foreign-born population or immigrants of Kansas changed by 24.0 percent between 2000 and 2007. Source: Migration P Source: Migration Policy Institute

5. Immigrant Population and Health

6. 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.

7. Demographic Characteristics of Immigrants in Kansas

8. 57.4 % of immigrants in Kansas are from Latin America (South America, Central America, Mexico, and the Caribbean) 48.5 % were born in Mexico

11. Age Distribution

12. Geographic Location and Dispersion of Immigrants

14. United States Race/Ethnicity Projections 2010‐2050(by percentage) 12.6 15.5 17.8 20.1 22.3 24.4 81.00 79.3 77.6 75.8 73.9 72.1 12.70 13.1 13.5 13.9 14.3 14.6 3.8 4.6 5.4 6.2 7.1 8.0 2.5 3.0 3.5 4.1 4.7 5.3

15. Kansas City, Mexico and Orient Railway Company Routes

16. Historical Outlook of Latinos in Kansas Source: Argentine, Kansas: The Evolution of a Mexican-American Community, 1905-1940; Laird, Judith Fincher; 1975, dissertation

17. Atchison Topeka Santa Fe Section Crew Pauline, Kansas 1913

18. Fiesta Belles, Topeka, Kansas 1933

19. 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%

20. Health and Latinos in Wyandotte County

21. Hispanic Birth RatesWyandotte County, KS • Hispanic birth rate 26.9 per 1,000 population • Non-Hispanic birth rate 16.5 per 1,000 population

22. HOSPITAL DIAGNOSIS STATISTICSCOMPLICATONS 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

23. LATINOS ARE MORE LIKELY TO BE UNINSURED • Poverty • Median household income in Kansas - $42.920 • Latinosmedian household income in Kansas - $19.500

24. 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

25. “CIGARETTESMOKING… is the chief, single, avoidable cause of death in our society and the most important public health issue of our time.”

26. Smoking among Latinos

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

28. Cigarette Smoking Prevalence Study of Latinos Baseline, 2009

29. Acculturation and Smoking Behavior in Latino Men and Women

30. Light and Non-Daily SmokersTobacco Use Supplement CPS, 2003

31. 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)

32. Smoking Cessation Disparities and Latinos 1. Advice from the healthcare providers 2. Pharmacotherapy 3. Behavioral counseling

33. 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.

34. 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.

35. 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

36. Study 1Are Latino smokers getting identified in community clinics and receiving treatment?

37. 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.

38. 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).

39. 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.

40. 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%).

41. 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.

42. Study 2 • Improve utilization of the evidence clinical guidelines. • Identifying smokers. • Referring them to treatment.

43. 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.

44. Methods TWO SAFETY NET CLINICS Identify Smokers 3. Personalized Health Education 1. Quitline Referral 2. Provider Summary Provider Patient Outcomes

45. Outcome Measures Recruitment Kiosk Utilization 2 mo FU Utilization of Smoking Cessation Resources Previous Use of Smoking Cessation Resources Interest in Using Smoking Cessation Resources

46. 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

48. 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)

49. 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

50. 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