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Nicotine dependence, acculturation, and family attitudes among Hispanic smokers

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Title:
Nicotine dependence, acculturation, and family attitudes among Hispanic smokers
Creator:
Vaughan, Ellen Lee
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English
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51 leaves : ; 28 cm

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Subjects / Keywords:
Hispanic Americans -- Tobacco use -- Colorado -- Denver ( lcsh )
Hispanic Americans -- Cultural assimilation -- Colorado -- Denver ( lcsh )
Hispanic American families -- Attitudes -- Colorado -- Denver ( lcsh )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Bibliography:
Includes bibliographical references (leaves 47-51).
General Note:
Department of Psychology
Statement of Responsibility:
by Ellen Lee Vaughan.

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|University of Colorado Denver
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|Auraria Library
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ocm48713282
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LD1190.L645 2001m .V38 ( lcc )

Full Text
NICOTINE DEPENDENCE, ACCULTURATION,
AND FAMILY ATTITUDES AMONG HISPANIC SMOKERS
by
Ellen Lee Vaughan
B.A., University of Montana, 1996
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Master of Arts
Psychology


This thesis for the Master of Arts
degree by
Ellen Lee Vaughan
has been approved
by
itchell Handelsman


Vaughan, Ellen Lee (M.A., Clinical Psychology)
Nicotine Dependence, Acculturation, and Family Attitudes Among Hispanic Smokers
Thesis directed by Associate Professor Michael Zinser
ABSTRACT
There is a pressing need for research addressing tobacco use among ethnic minorities.
Hispanics, the focus of this research, are a rapidly growing population characterized
by great variation in immigration status, education, and language usage. I
investigated the effects of acculturation, a process that includes changes associated
with contact with a different culture, on smoking rates, nicotine dependence and
family attitudes about smoking. 149 patients at an urban health clinic in Denver,
Colorado completed a survey addressing socio-demographic questions, an
acculturation scale, smoking history, and questions related to degree of family
influence on smoking behaviors. They also provided a breath sample for analysis of
carbon monoxide, a measure that reflects smoking. The sample was 73% Hispanic
and 18% white. Paralleling national trends, Hispanics reported significantly lower
levels of education and income relative to whites. The Hispanics were divided into
low acculturation (42%) and high acculturation groups (58%). Overall smoking
prevalence for Hispanics was 41%, but there was a striking difference between low
acculturation (24%) and high acculturation (54%) groups. Contrary to prior research,


we found that self-report of smoking among Hispanics was highly honest, and was
consistent with carbon monoxide analysis. Expected differences as a function of both
gender and acculturation in daily consumption rate, level of dependence, readinesses
to quit smoking, and confidence in ability to quit were not found. It is likely that our
low sample size accounts for this result. Low-acculturated Hispanics gave
significantly higher ratings on measures of family influence and support. Limitations
of this research and implications for both treatment and further research are
discussed.
This abstract accurately represents the content of the candidates thesis. I recommend
its publication.
Signed
Michael Zinser
IV


ACKNOWLEDGMENT
I would like to acknowledge and thank Dr. Thomas MacKenzie and the staff at the
Westside Family Health Center for their support and patience. I would also like to
thank Dr. Michael Zinser for his ongoing encouragement and guidance.


CONTENTS
Tables..............................................................viii
CHAPTER
1. INTRODUCTION.................................................1
Literature Review.........................................1
Study Objectives and Hypotheses...........................6
2. METHODS......................................................8
Study Population..........................................8
Procedures................................................9
Measures.................................................11
Survey.............................................11
Socio-demographic Variables..........11
Acculturation Scale.........................12
Fagerstrom Test for Nicotine Dependence.....12
Smoking History.............................13
Stage of Change and Self-efficacy...........14
Family Variables............................15
Carbon Monoxide....................................15
3. RESULTS ....................................................17
vi


Statistical Analysis
17
Participants.....................................18
Validity of Self-reported Smoking Status.........20
Smoking History and Dependence Level.............20
Motivations and Attitudes Relevant to Cessation..22
Familial Orientation, Acculturation Levels, and Smoking.22
4. DISCUSSION.................................................25
Validity of Self-reported Smoking Status.........26
Smoking History and Dependence Level.............27
Familial Orientation, Acculturation Levels, and Smoking ...29
Limitations and Future Directions................30
APPENDIX
A. ENGLISH QUESTIONNAIRE...................................33
B. SPANISH QUESTIONNAIRE....................................40
REFERENCES 47
vii


TABLES
Table
3.1 Participant Characteristics................................................18
3.2 Hispanic Participant Characteristics by Gender and Level of Acculturation.19
3.3 Smoking History and Dependence Level by Group..............................21
3.4 Mean Ratings of Family Influence and Support by Acculturation Group........23
viii


CHAPTER 1
INTRODUCTION
Literature Review
This research addresses the effects of acculturation on smoking in Americans
of Hispanic origin. The need for such work was highlighted in the 1998 Report of the
Surgeon General, which noted that significant gaps in knowledge about the smoking
patterns and correlates of American ethnic and racial minorities stand as major
obstacles to achieving reductions in their smoking rates.1 This urgency is
underscored by the fact that smoking rates in minorities remain high2 and by
projections indicating that the rapidly growing American minority population will
constitute almost half of the total within the next 50 years.3 The US Census Bureau
reported a 48% rise in the Hispanic population from 1990-1998.4 In 1999 11.7 % of
the population was Hispanic; this number has risen to 12% in 2000.5,6 Several authors
have echoed the Surgeon Generals message with specific reference to Hispanics and
note the need for culturally relevant research.7'9 The results of culturally relevant
research have implications for the development of culturally tailored smoking
cessation interventions.
The present proposal aims to address these needs by surveying Hispanics
attending an urban public health outpatient clinic. Such sites appear optimal on a
1


number of bases. Minorities, and particularly Hispanics, are considerably more likely
to lack insurance and rely more heavily on hospital-based facilities such as clinics and
outpatient departments for their usual care,10 and are more concentrated in inner
cities.11 Further, this population is characterized by the variables most consistently
linked to high smoking rates and difficulty in achieving cessation: the poverty rate
among American Hispanics exceeds 25%,12 and educational achievement is
considerably lower than that of whites.13
Fundamental questions about Hispanic smoking prevalence, daily
consumption rate, and associated nicotine dependence remain unanswered. Such
information is needed for effective use of widely used and well-supported nicotine
replacement therapies. There is evidence that self-report, the sole basis for most
assessments of smoking patterns among Hispanics, may be inadequate. Perez-Stable
and colleagues,14 using serum cotinine samples to validate self-reported smoking
status in the Hispanic Health and Nutrition Examination Survey, found evidence of
significant underreporting of smoking. Similarly, Navarro found that agreement
between self-report and proxy report of smoking status was lower among Hispanics
than other ethnic groups.15 Several authors have noted that assessing carbon
monoxide is useful as a valid and non-invasive way to corroborate self-reported
smoking status.16'18 These and other authors have called for further research using
objective validation of reported smoking status among Hispanics.
2


A related problem is the absence of validated measures of nicotine tolerance
and dependence for Hispanics. The psychometric properties and concurrent validity
of the most widely used instruments, the Fagerstrom Tolerance Questionnaire (FTQ)
and the Fagerstrom Test for Nicotine Dependence (FTND), have been thoroughly
investigated in white subjects,1921 but not in Hispanics. Indeed, the primary available
measure of dependence among Hispanics is self-reported daily consumption, an index
that has been called into question; as noted, there is evidence that Hispanics
underreport the amount they smoke. This finding makes the use of the number of
cigarettes as an indicator of dependence a major limitation in research on smoking.
Further, the lack of correspondence between daily smoking rate and dependence has
been shown in African Americans. This finding has been attributed to racial
differences in both nicotine metabolism and cigarette choice (mentholated vs. non-
mentholated). The limited evidence available suggests that Hispanics may be less
tolerant than other groups of smokers, as indexed by number of cigarettes smoked per
day9 and latency to first cigarette.22 Although conclusions must be regarded as
tentative given the limitations of self-report methodology,1'78 both overall smoking
prevalence and daily smoking rate appear to be lower among Hispanics than among
non-Hispanic whites.182425
The assessment of readiness to change smoking behavior, both between and
within cultures, is another important element in the development of culturally relevant
3


smoking cessation programs. The most widely used model of behavioral change in
the smoking cessation literature, Prochaska and DiClementes trans-theoretical
formulation,26 has been largely absent from the literature on Hispanics and other
racial and ethnic minorities. This Stages of Change model has been shown to
predict successful quit attempts and has served as a useful guide for treatment
intervention.26,29 In one of the few studies that applied this model to Hispanics,
Palinkas and colleagues found greater proportions of Spanish-speaking Hispanic
smokers in the action stage than both English-speaking Hispanic and non-Hispanic
white smokers.7
Culturally relevant research using a population with many recent immigrants
must take acculturation into account. This complex process includes adoption of the
dominant cultures language, values and behavior.' Several acculturation scales
have developed, and these have been useful in identifying related differences in
mental and physical health status. These measures have only recently have been used
in research into smoking and Hispanics.31'35 Although language usage and preference
account the majority of the variance in acculturation, the consensus is that other
factors such as generational status and degree of association with other Hispanics
should be included in acculturation assessment.30'31
Broad characterizations about racial or ethnic groups, particularly a group
with many recent immigrants that vary in level of acculturation, are often misleading.
4


Such is the case with research on Hispanics, who are often shown to smoke less than
whites. Palinkas has shown that when acculturation (as indexed by language
preference) is considered, the difference is attributable to the fact that Spanish-
speaking Hispanics smoke less than their English-speaking counterparts.7 Other
research has shown that gender interacts with acculturation: Hispanic women but not
Hispanic men increase smoking rates as they acculturate.23 Here, acculturation
appears to be antithetical to healthy behavior, at least in Hispanic women.
Social values such as family cohesion, trust, and positive social relationships
are central to Latino cultures36 and may change with acculturation. Other research on
smoking in traditional Hispanics is consistent with this theme, showing for example
that in contrast with American whites, smoking is more associated with social
situations than with habitual activities.9 Also consistent are findings about
differences between Hispanic and non-Hispanic smokers in cessation motivation.
The former are significantly more likely to cite social motives such as desire to be a
good role model for their children and concern about the effects of smoking on both
their children and others as reasons to quit. Although some research suggests that
US-born Hispanic women who smoke have less cohesive families than native
Hispanic women who smoke,34 there are little comparative data from within this
ethnic group bearing on the relations among acculturation, family attitudes, values,
and smoking. Several authors have explored changes in family values with
5


acculturation and recommended the use of family within culturally relevant
jz: 10
interventions.' However, the involvement of family in smoking patterns and
decisions has received little attention in the literature. Improved understanding of
these influences should help us craft more effective interventions for Hispanics.
Study Objectives and Hypotheses
The general applied aim of the present research is to investigate the smoking
patterns and correlates of urban Hispanics varying in English language proficiency in
order to better tailor cessation interventions for this diverse population. A central
theoretical aim is to elucidate the mechanisms underlying the smoking increases
attending acculturation. The hypotheses detailed below relate to the following
relevant grouping factors: smoking status (current/former/never), gender and
acculturation (high/low).
I predict that:
highly acculturated Hispanics will show higher smoking prevalence, daily
cigarette consumption, nicotine dependence, and longer duration of habitual
smoking relative to low-acculturated Hispanics.
all of these acculturation effects will be seen in women.
6


among men increased acculturation will be associated with a lower prevalence
of cigarette smoking, but higher daily consumption and nicotine dependence.
overall, Hispanic men will have higher prevalence, daily cigarette
consumption, and nicotine dependence than women.
low-acculturated Hispanics will place higher in the Stages of Change
Continuum and will report greater confidence in ability to quit than will
highly acculturated Hispanics.
low-acculturated Hispanics will report greater levels of family orientation than
will highly acculturated Hispanics.
Hispanic self-report of smoking status will show low levels of validity overall
and will be lower than that for whites.
7


CHAPTER 2
METHODS
This proposal received approval from the Colorado Multiple Institutional
Review Board and the Human Subjects Research Committee at the University of
Colorado at Denver. All procedures conformed with the American Psychological
Associations standards for the ethical treatment of human research participants.'
Study Population
Participants were recruited from Westside Family Health Center in Denver,
Colorado. Westside is a community-based, outpatient healthcare facility serving a
predominantly Hispanic population. Westside patients who are at least 18 years of
age were included. Exclusion criteria were inability to speak either English or
Spanish, and incapacity or difficulty attributable to apparent medical condition or
drug or alcohol intoxication. In addition, patients were also required to be literate in
either English or Spanish to participate. Other exclusion criteria include family
8


members of patients, patients seeking either medication refills or lab tests only, and
patients being seen in obstetrics or dental clinics.
Any adult patient seeking medical treatment who matched these criteria was
eligible for participation in the study. Using both smokers and non-smokers allowed
us to determine base rate of smoking within this clinic and to assess the validity of
self-reported smoking status. Although Hispanics are the focus of this research,
persons from other ethnicities were not excluded from participation in the study.
Their data were not included in the analyses, however.
Procedures
All patients seeking services at the Westside Family Health Center register at
business services when they are given an appointment. Research assistants
approached patients after they received their appointments and asked whether they
would be willing to participate in the study. Subjects were told the purpose of the
study, the aim of improving cessation services, and that participation would not
interfere with receipt of medical care. Research assistants invited and addressed
participant questions about the nature and purposes of the study, reminded them that
they would be free to withdraw from the study at any time, and assured that the
survey would not be allowed to interfere with their appointment or medical care. A
9


copy of the consent form was given to each participant. The entire procedure lasted
approximately 25 minutes.
All communications and forms were in the participants preferred language
(Spanish or English). The following steps were taken to ensure monolingual Spanish-
speaking participants were allowed to autonomously decide to participate in the
study: both the consent form and survey were translated into Spanish; research
assistants were bilingual and able to summarize the purpose of the study; and these
assistants emphasized both that participation was completely voluntary, and that
refusal to participate would not result in negative consequences in the receipt or
quality of medical care.
After consent was obtained, the research assistant requested a carbon
monoxide reading. The research assistant explained the nature of carbon monoxide
and reason for and manner of the measurement. The participant was given a sterile
mouthpiece, and asked to provide a breath sample. That reading was recorded on the
survey form. The participant was then given a clipboard, the survey and a pencil, and
asked to complete the survey. The research assistant remained within easy access of
the participant, and offered to answer any questions. Participants called to their
appointment prior to completion of the study were asked to complete their survey
after their appointments. Those participants who refused or did not complete the
survey were considered voluntarily withdrawn from the study. The participants were
10


thanked for their participation, and were invited to call the number listed on the
consent form if they had further questions.
The number of participants accrued was 149. A conservative estimate of the
proportion of patients who either refused to participate or signed a consent form but
did not complete the survey procedure was 25%.
Measures
Survey
The survey consisted of questions addressing socio-demographic
information, a short acculturation scale for Hispanics40, smoking history information,
the six items comprising the Fagerstrom Test for Nicotine Dependence2241, items
needed to locate the subject on the Stages of Change continuum and items derived
36 38
from published research on social and familial factors influential for Hispanics.'
The English-language version of this survey is provided in Appendix A, and the
Spanish version in Appendix B.
Socio-demographic Variables. The first portion of the questionnaire
contained six questions addressing socio-demography. These included age, race and
ethnicity, gender, marital status, years of education, and income. For race and
11


ethnicity, participants who marked more than one option were included in the Other
category of race/ethnicity. We also asked the number of years lived in the United
States (U.S.). For those participants spending their entire life in the U. S., their age
was entered into this variable.
Acculturation Scale. The Short Acculturation Scale for Hispanics was
devised and validated by Marin et al.40 and has been used in several studies
evaluating smoking patterns among Hispanics.9,23,24 They report that the scale has a
coefficient alpha of .92 and have shown that it relates to generational status, length of
residence in the U.S. and self-evaluation of acculturation. The scale consists of 12
items addressing language usage and preference and degree of association with other
Hispanics. The items were presented in a five-point Likert format. Per instruction by
the scale author, I scored the acculturation scale by summing item responses and
dividing by the number of questions (G. Marin, personal communication, June, 2001).
Scores of 2.99 and above are considered high levels of acculturation while scores
below 2.99 are low levels of acculturation.
Fagerstom Test for Nicotine Dependence. The Fagerstrom Test for Nicotine
Dependence (FTND) is the most widely used measure of nicotine dependence and
shows acceptable levels of internal consistency. Scores on the FTND have been
12


shown to relate to consumption variables and difficulty achieving cessation.19'21
Fagerstrom and colleagues reported a mean FTND score of 4.3 in a telephone survey
of 753 adult smokers in the United States.42 The six scale items address daily
cigarette consumption, latency to first cigarette of the day, difficulty refraining from
smoking where it is forbidden (yes/no), most difficult cigarette of the day to give up
(first vs. any other), temporal distribution of smoking (more during the hour after
waking vs. any other pattern), and smoking even when illness requires bed rest
(yes/no).
Smoking History. Five questions standard in the smoking epidemiology
literature were used to address smoking history. Two questions used to establish
smoking status (current, former, never) were derived from the Center for Disease
-j
Controls National Health Interview Survey/ These were: Have you smoked at
least 100 cigarettes in your life? (yes/no) and How often do you smoke? (every
day/ some days/ not at all). Current smoker status is defined as having smoked 100
cigarettes and report of smoking every day or some days; former smokers are those
who indicated they have smoked at least 100 cigarettes in their lives but do not
currently smoke; and never- smokers are those who have smoked fewer than 100
cigarettes and do not smoke currently. Participants were also asked when they last
13


smoked a cigarette, the number of years they have smoked, and number of smokers in
their household.
Stages of Change and Self-Efficacy. Prochaska and DiClementi have
developed a brief measure, Stages of Change instrument, that has gained wide
acceptance due to its high reliability and ability to predict outcome.27'29 The self-
report measure assesses readiness to change by having subjects indicate whether they
are: not considering quitting smoking (pre-contemplation), planning to quit within the
next year (contemplation), planning to quit within the next 30 days (preparation), or
actively attempting to quit (action), or successfully quit (maintenance). There is one
question addressing stage of change.
Bandura (as cited in Broudeaux, Carmack, Scarinci and Brantly) has
developed the construct of self-efficacy and defines it as an individuals ability to
perform a behavior that will secure a desired outcome. In the tobacco literature, this
construct is most commonly assessed by a single item where participants rate how
confident they are that they will not be smoking in a particular amount of time. We
used this question in 10-point Likert format, with anchors not at all confident (1)
and very confident (10).
14


Family Variables. As noted, researchers have only recently begun to examine
acculturation effects on familial functions in attempts to explain both smoking uptake
and cessation.35'37 These reports have not yielded validated scales, but have
demonstrated the utility of the focus. I derived 14 questions from these references,
each printed in five-point Likert format with descriptive anchors indicating strong
agreement (5) and strong disagreement (1). This set of questions included the
following dimensions: degree of family involvement and influence in decisions to
either quit or continue smoking; and degree of family support of cessation. I also
included a not applicable option for those participants who did not have children.
Carbon Monoxide
Prior to completion of the questionnaire, each participant provided a breath
sample for carbon monoxide analysis. This measure is safe, non-invasive, and is a
reliable and valid measure of smoking status.17,18 Carbon monoxide was measured by
having subjects hold their breath for fifteen seconds and then exhale into a sterile,
disposable mouthpiece attached to the carbon monoxide monitor. Middleton and
colleagues identified a carbon monoxide reading of 6 parts per million (ppm) or
greater as a reasonable cutoff to identify smokers.18 They also noted that the half-life
for carbon monoxide has been reported to be between five and six hours.
15


Drawing from Middletons work18,1 used the following decision rules to
evaluate the validity of self-report of smoking status: a. Valid report: Participants who
had a carbon monoxide level exceeding 6 parts per million (ppm) and reported
smoking within the past 12 hours; and participants who denied smoking coupled with
a carbon monoxide of less than 6 ppm, and b. Discrepant report: Participants with
carbon monoxide reading exceeding 6ppm and denial of smoking.
16


CHAPTER 3
RESULTS
Statistical Analysis
Data were analyzed using SPSS for Windows, Version 10.0. Descriptive
statistics were computed for socio-demographic variables using the entire sample, but
reports of these and inferential statistical analyses are restricted to Hispanics.
Analysis of variance (ANOVA) was used to test hypotheses related to grouping
factors. Non-parametric Mann-Whitney Us were used to test hypotheses relating to
smoking prevalence and the Kruskal-Wallis test was used for hypotheses relating to
Stage of Change.
I used a .05 probability level as a criterion for significance in analyses
involving participant characteristics and smoking variables. Given that the number of
comparisons involving the family attitude variables was large and incurred substantial
risk of Type 1 error, I used a more stringent criterion: the standard .05 level divided
by the number of analytical comparisons in a related group of questions. Thus, for
the nine questions addressing family influence on smoking behavior, I used a .006
criterion. For the four questions addressing family support in quitting, I used a .0125
level.
17


Participants
Completed surveys and carbon monoxide samples were obtained from 149
patients at the Westside Family Health Center in Denver, Colorado. Socio-
demographic data are presented in Table 3.1. I present results for Hispanic and non-
Hispanic white participants as the low frequencies of participants identifying as
African American (4), American Indian (2) and other (7) render means unstable. As
shown females predominate in both groups.
3.1 Participant Characteristics
Race/Ethnicity Hispanic White
Percent 73.2% 18.1%
Number 109 27
% Female 67% 66.7%
Age 44.13 40.67
Education 10.1 13.1
Income $9238 $13846
ANOVA analyses revealed that Hispanics reported significantly lower levels
of both education (Hispanic M = 10.1, SD = 2.8; white M = 13.1, SD = 2.1, F (1, 134)
= 26.95, p< .0001) and income (Hispanic M = 9,239, SD = 8,389; white M = 13,846,
SD = 13,157, F = 4.969, g =.027). The two groups did not differ in age.
18


As this research focuses on effects of gender and degree acculturation (high/
low) among Hispanics, I present results of analyses of participant characteristics
separated by these factors. These are shown in Table 3.2.
3.2 Hispanic Participant Characteristics by Gender and Level of Acculturation
Hig l Acculturation Low Acculturation
Female Male Group Mean Female Male Group Mean
Number 40 23 63 33 13 46
Age 41.95 48.48 44.3 42.06 48.75 43.84
Education 10.95 11.7 11.2 8.64 8.31 8.5
Income 10,113 10,108 10,111 6,742 11,346 8,043
Highly acculturated Hispanic were slightly more predominant in our sample
than were low-acculturated Hispanics (58% vs. 42%). ANOVA analysis reveals a
significant difference between high and low acculturation participants on educational
level (high M = 11.2, SD = 2.11; low M = 8.54, SD = 2.89, F (1, 107) = 31.295, p<
.0001). There were no differences between these groups on age and annual income.
For gender, ANOVA analysis shows significant differences in mean age (women M =
42, SD= 14.46; men M = 48.57, SD= 18.36, F (1, 106) = 4.084, p = .046). There
were no differences between Hispanic men and women in education level and
income.
19


Validity of Self-reported Smoking Status
Using the decision rules described earlier, I calculated the percent of valid
report of smoking status by group. In both Hispanic and white participants, report
was highly valid: 93% for whites and 97% for Hispanics. Within the Hispanic group,
the self-reports of both highly acculturated (93%) and low acculturated (100%)
smokers were comparably valid. I then examined the validity rates among
participants who denied smoking. These rates were 88% among whites and 97%
among Hispanics. Figures for highly acculturated and low acculturated participants
were 92% and 100%, respectively. None of these differences approached
significance.
Smoking History and Dependence Level
The baseline-smoking rate of all participants was 42.3%. Among Hispanics,
41.3% were current smokers, 15.6% were former smokers and 43.1% never-smokers.
The mean number of cigarettes smoked per day by Hispanics was 9.56. Table 3.3
presents smoking history and dependence level data for acculturation and gender.
20


3.3 Smoking History and Dependence Level by Group
Hig i Acculturation Low Acculturation
Female Male Group Mean Female Male Group Mean
Number 40 23 63 33 13 46
% Current Smoker 45% 69.6% 54% 24.2% 23.1% 24%
Daily Smoking Rate 10.22 9.00 9.65 9.25 9.33 9.27
Years Smoking 18.4 25.4 21.7 19.38 24.7 20.8
FTND 2.78 2.69 2.74 3.25 1.67 2.82
CO 17.22 14.31 15.85 10.38 17.33 12.27
As seen in table 3.3, smoking prevalence among highly acculturated Hispanics
was more than double that seen in low-acculturated Hispanics. This difference was
significant (Mann-Whitney U p = .002). The predicted effects of gender on smoking
variables within each acculturation level were not found. Male and female
prevalence did not differ significantly in either group. There was a trend for highly
acculturated Hispanic males to smoke greater that highly acculturated women (Mann-
Whitney U, p = .062). The difference between high-acculturated women and low-
acculturated women (45% vs. 24.2%) on smoking prevalence approached
significance (Mann-Whitney U, p = .067). There were no significant effects of either
gender or acculturation on daily smoking rate, years smoking, dependence (as
measured by the FTND) or carbon monoxide.
21


Motivations and Attitudes Relevant to Cessation
Hispanic participants placed themselves in one of three levels of readiness to
attempt cessation (Stage of Change): pre-contemplation, contemplation, and
preparation. For high acculturation participants, 48.5% were in pre-contemplation,
15.2% in contemplation, and 36.4% in preparation. For low acculturation, 54.5%
were in pre-contemplation, 18.2% were in contemplation and 27.3% were in
preparation. The distributions of participants across these categories did not differ as
a function of acculturation (Kruskal-Wallis p = .80), nor were there any significant
gender effects.
There was no difference between participants with high and low acculturation
scores in confidence in ability to quit (low acculturation M = 6.5, SD = 3.9, high
acculturation M = 5.8, SD = 3.5; F=.324, p =.572). There was also no difference
between men and women on this question. The overall mean of 5.9 corresponds to a
rating just beyond the midpoint of this 10-point scale.
Familial Orientation, Acculturation Levels, and Smoking
I used ANOVA to compare low and high acculturation Hispanics on family
attitudes relevant to cessation. I grouped the 13 of the 14 items into two groups, one
set addressing degree of family influence on smoking behavior, and another
addressing degree of family support for cessation. These results are presented in
22


Table 3.3. A significant difference was found for one question, and borderline
significance was found for a second. Participants with low acculturation scores were
more likely to indicate that their family could better help them quit smoking than a
doctor, priest, or quit smoking program (F (1,39) = 8.771, p = .005). The difference
in rating of family involvement in a decision to smoke narrowly missed significance
(F (1,41) =7.718, p = .008). The fourteenth item not presented in the table did not
differ by acculturation group.
Table 3.4 Mean Ratings of Family Influence and Support by Acculturation Group
Acculturation Level
Family Influence Item High Low F P
My family influences my decision to smoke. 2.29 3.67 7.718 .008
Smoking is a bad example for my children. 4.42 4.56 .171 .681
Smoking harms the health of my children. 4.69 4.60 .115 .736
I would discuss with my family my decision to quit smoking. 4.00 4.18 .216 .644
I smoke with my family even when they are not smoking or do not smoke. 3.15 3.78 1.545 .221
I smoke around children. 2.81 2.70 .040 .843
My family wants me to quit smoking. 3.97 4.70 3.850 .057
My family motivates me to quit smoking. 3.63 4.25 2.31 .152
Quitting smoking would benefit the health of my family. 4.50 4.67 .294 .591
23


Table 3.4 (Cont.)
Acculturation Level
Family Support Item High Low F P
My family can better help me quit smoking than a doctor, priest, or quit smoking program. 3.00 4.36 8.771 .005
My family would support me in my decision to continue smoking. 2.47 2.33 .071 .791
My family would support me in my decision to quit smoking. 4.52 4.33 .256 .616
When I choose to quit smoking, my family will help me. 4.25 4.58 .995 .324
24


CHAPTER 4
DISCUSSION
My findings provide inconsistent support for predictions. I will review these
findings in the context of the broader literature, and discuss implications and
limitations. I begin by examining our population and the generalizations this sample
permits.
Our results show that the educational level and mean income of participants
are consistent with those of the American Hispanic population. Hispanics reported
low levels of both education and income, significantly below those for non-Hispanic
whites. These data are consistent with census data showing that Hispanics have lower
high school graduation rates than non-Hispanic whites and that nearly a third have
less than ninth grade education.6,13 These same reports show that Hispanics have
lower income compared to their non-Hispanic white counterparts. In our sample, low
levels of educational attainment are particularly characteristic of participants with low
acculturation scores, who in turn would be more likely to be more recent immigrants.
Although generalizations about the overall American Hispanics sample based on such
a narrow sample must be tentative and subject to replication, these findings lend some
support to the validity of the influences described below. A clear implication is that
25


education, given its powerful correlations with income and smoking rates, may be a
primary means of addressing disparities.
Validity of Self-Report
Contrary to both our predictions and prior research indicating that Hispanics
often underreport smoking, our results reveal a high level of valid self-report. Carbon
monoxide findings were closely related to self-reported smoking status for both
Hispanics and whites. Among subjects reporting non-smoking, four subjects had
carbon monoxide levels that indicated smoking status. Among these participants, two
participants reported smoking marijuana that day and two, with borderline carbon
monoxide levels of 6 and 7 ppm respectively, maintained that they did not smoke.
The evidence of deception presented by Perez-Stable14 is derived from a national
survey, and our results alone cannot be sufficient to contradict those from their larger
sample. The discrepancy may be attributable to our high refusal rate (approximately
25%). However, even if we assume that most of these patients who refused to
participate in the study and provide carbon monoxide sample would have been
deceivers, the rates of valid self-report would still have been large. Clearly, further
research is needed.
26


Smoking History and Dependence
Our data reveal a disturbingly high prevalence of smoking among Hispanics,
more than double that reported in national data for Hispanics as a whole.1,2 The rate
seen in our sample of low-acculturated Hispanics (24%) was comparable to those
national findings. Our results thus highlight the importance of separating Hispanics
by acculturation level. They suggest that the adoption of what is perceived to be the
habit of the dominant culture, driven by powerful influences, produces unhealthy
behavior choices. It is also possible that our high refusal rate distorted results. The
most common report of these refusers was that they did not smoke and were thus
not interested. Although we have no systematic data on relative rates of refusal
among the two acculturation groups, our impression was that they were more
common among low-acculturated patients. Assuming this, the disparity in smoking
rates might be even larger. If refusals were randomly distributed across acculturation
groups, the effect would still be substantial.
The predicted differences in other smoking consumption and dependence
variables (mean number of cigarettes smoked per day, years of smoking, FTND
scores and carbon monoxide) as a function of acculturation level and gender were not
found. In these comparisons, sample size is the greatest limitation to interpretation
of results. This is compounded by the fact that we had up to four groups (two levels
27


of gender crossed with two levels of acculturation), further lowering the number of
participants in each cell. Other research has demonstrated the opposite, that
participants with high acculturation scores smoked more cigarettes per day. '
Nevertheless, the mean number of cigarettes smoked per day in both acculturation
groups is similar to those reported for larger groups of Hispanic smokers; this rate is
lower than those previously reported for other racial and ethnic groups.2,7,24 Although
our data revealed no difference in mean FTND scores as a function of acculturation
level, both levels of acculturation had lower mean FTND scores than reported in a
U.S. sample by Fagerstrom and colleagues.42 These data are consistent both with
research indicating that Hispanics have lower overall dependence9 and with our
samples relatively low mean consumption rate. The absence of group differences in
carbon monoxide level is likely a direct function of the fact that these groups smoke
at similar rates.
Both high and low acculturation groups and both men and women had
comparable representations of participants in the pre-contemplation, contemplation,
and preparation stages of change. I predicted an effect for acculturation but not for
gender. The failure to confirm the former effect is likely due to our lack of statistical
power. The same problem may have accounted for the lack of gender and
acculturation effects on self-efficacy.
28


Familial Orientation. Acculturation Levels and Smoking
My prediction that acculturation would be associated with decreases in levels
of self-report of family influence in and support of smoking cessation received
limited support. Compared to highly acculturated Hispanics, low-acculturated
Hispanics reported that the family was more influential in decisions to smoke; this
difference narrowly missed achieving statistical significance. A less conservative
procedure for controlling Type I error would have produced a significant effect, and I
thus argue that this finding may be interpreted with caution. Although the
interpretation of this question may be ambiguous, it is reasonable to conclude this
group thinks about their family more in relation to their decisions about smoking.
Low-acculturated Hispanic smokers also indicated they thought their family
could better help them quit smoking than a doctor, priest or quit smoking program.
This may have treatment implications: professionals may wish to put a greater
emphasis on enlisting the family in support of members who attempt cessation. This
is especially important for patients who are resistant to formal quit smoking
programs. It is also a call for professionals to develop programs that either involve
the family or allow family members to attend.
For the remaining family attitude questions, the absence of a statistically
significant effect does not necessarily diminish the importance of this factor. Overall
29


means for these questions indicate that both high and low acculturation groups have a
strong orientation toward family. Both groups of Hispanic smokers report high levels
of family support for a decision to quit smoking and resistance to continued smoking.
Further, both groups indicated that family would help them during the quit process.
Both groups also agreed that smoking is a bad example for their children, harms the
health of their children, and that quitting would benefit the health of the family. On
the whole, these results indicate that a family-oriented quit smoking program may be
particularly well suited to Hispanics regardless of acculturation level.
Limitations and Future Directions
As noted, our sample appears to be similar in important respects to American
Hispanics. Results of this limited cross-section will require replication before they
are accepted, however. The most significant limitation of this research is its lack of
statistical power, largely due to our sample size. Cohen has shown that statistical
comparisons involving two groups given an effect of moderate size require a
minimum of 64 subjects per cell to achieve significance.43 We did not have this
number available for any of our comparisons. Thus, some questions remain open:
there is no way to determine whether the null hypotheses have been rejected or
accepted. Nevertheless, it should be noted that in general our significant results are
consistent with those found in previous studies. Further, the significant effects of
30


acculturation on measures of familial influence and support emerged even in spite of
our low power, suggesting these are powerful influences that merit further attention.
Another important limitation of our findings is the significant rate of refusal to
participate. This has been discussed earlier, and here I will offer suggestions for
future research. Given that low-acculturated Hispanics appeared to be more likely to
refuse, it may be beneficial to employ researchers who are both completely fluent in
Spanish and appear to be Hispanic. Much prior research has shown that Hispanics,
and particularly those subject to suspicion about immigration status are more open
and compliant with those they see as like themselves.44 Another possible reason for
refusals, and perhaps more likely given the comments offered by Westside patients, is
that these persons indeed were not interested because they did not smoke. Thus,
future research efforts may be aided by the provision of incentives for participation.
Given the paucity of research on this population, compounded by the common
lack of consideration of acculturation effects, the general need for further research is
clear. More specifically, the following questions need attention: a) is the FTND a
valid measure of dependence in both Hispanic acculturation groups? (this would
require large samples, factor analysis and concurrent data on smoking behavior) b)
does dependence vary as a function of other ethnic groupings? c) can existing
measures for nicotine dependence be improved? d) by what mechanisms does
31


acculturation affect family values relevant to health behavior? and e) how might
cultural and familial influences be enlisted to enhance treatment?
32


APPENDIX A
ENGLISH QUESTIONNAIRE
, ft/:
Date:
ll'
SMOKING QUESTIONNAIRE

S#:
Researcher Initials:
CO:
AGE:______
RACE/ETHNICITY:
D White
D Black/African American
D Hispanic/Latino/Chicano
____Mexican
____Puerto Rican
____Dominican
____Central American
____South American
D American Indian
D Asian
D Other:________________
GENDER:
D Female
D Male
MARITAL STATUS:
D Single
D Married
D Divorced/Separated
D Widowed
33


Please circle highest grade in school you finished.
Less than 6 6 7 8 9 10 11 12 13 14 15 16 over
What is your yearly income?
$0 to $5,000 $20,000 to $25,000 $40,000 to $45,000
$5,000 to$ 10,000 $25,000 to $30,000 $45,000 to $50,000
$10,000 to $15,000 $30,000 to $35,000 D over $50,000
$15,000 to $20,000 $35,000 to $40,000
How long have you lived in the United States?
In general, what language(s) do you read and speak?
1 2 3 4 5
Only Spanish better Both English better Only
Spanish than English Equally than Spanish English
What was the language(s) you used as a child?
1 2 3 4 5
Only More Spanish Both More English Only
Spanish than English Equally than Spanish English
What language(s) do you usually speak at home?
1 2 3 4 5
Only More Spanish Both More English Only
Spanish than English Equally than Spanish English
In which language(s) do you usually think?
1 2 3 4 5
Only More Spanish Both More English Only
Spanish than English Equally than Spanish English
34


What language(s) do you usually speak with your friends?
1 2 3 4 5
Only More Spanish Both More English Only
Spanish than English Equally than Spanish English
In what language(s) are the T.V. programs you usually watch?
1 2 3 4 5
Only More Spanish Both More English Only
Spanish than English Equally than Spanish English
In what language(s) are the radio programs you usually listen to?
1 2 3 4 5
Only More Spanish Both More English Only
Spanish than English Equally than Spanish English
In general, in what language(s) are the movies, T.V. and radio programs you prefer to watch
and listen to?
1 2 3 4 5
Only More Spanish Both More English Only
Spanish than English Equally than Spanish English
Your close friends are:
1 2 3 4 5
All Latinos/ More Latinos About Half More Non-Latinos All
Hispanics than Non-Latinos &Half than Latinos Non-Latinos
You prefer going to social gatherings/parties at which the people are:
1 2 3 4 5
All Latinos/ More Latinos About Half More Non-Latinos All
Hispanics than Non-Latinos &Half than Latinos Non-Latinos
35


The persons you visit or who visit you are:
12 3 4
All Latinos/ More Latinos About Half More Non-Latinos
Hispanics than Non-Latinos &Half than Latinos
If you could choose your childrens friends, you would want them to be:
5
All
Non-Latinos
1 2
All Latinos/ More Latinos
Hispanics than Non-Latinos
3
About Half
&Half
4 5
More Non-Latinos All
than Latinos Non-Latinos
Have you smoked at least 100 cigarettes in your life?
D Yes
No
Do you smoke cigarettes every day, some days, or not at all?
D Every day
D Some days
D not at all
On average, how many cigarettes are you currently smoking per day?
When did you last smoke a cigarette? Date:_________ Time:
For how many years have you been smoking?________
How many smokers are there in your household (not including yourself)?
How soon after you wake up do you smoke your first cigarette?
D within 5 minutes
D 6-30 minutes
D 30-60 minutes
D after 60 minutes
36


Do you find it difficult to keep from smoking in places where it is forbidden, such as
in church, at the library, at the movies, etc.?
Yes
No
Which cigarette would you hate most to give up?
D the first one of the day
D any other
Do you smoke more frequently during the first hours after waking than during the rest
of the day?
Yes
No
Do you smoke if you are so sick that you are in bed most of the day?
Yes
No
Which of these best describes your interest in quitting?
D I plan to quit in the next 30 days
D I plan to quit in the next 6 months
D I plan to quit in the next year
D I plan to quit some day
D I doubt I will ever quit
If you now smoke, chew tobacco or use snuff and want to quit, how confident are you
that you will NOT be smoking in six months? Circle the number that best shows how
you feel.
12345678 9 10
not at all very
confident confident
37


Use the following scale to answer questions about your familys involvement in your
decision to quit smoking.
1. My family influences my decision to smoke.
Not Strongly agree Somewhat agree Neutral Somewhat disagree Strongly
applicable N/A 5 4 3 2 disagree 1
2. My family should help me quit smoking.
Not Strongly agree Somewhat agree Neutral Somewhat disagree Strongly
applicable N/A 5 4 3 2 disagree 1
3. My family would support me in my decision to quit smoking.
Not Strongly agree Somewhat agree Neutral Somewhat disagree Strongly
applicable N/A 5 4 3 2 disagree 1
4. My family would support me in my decision to continue smoking.
Not Strongly agree Somewhat agree Neutral Somewhat disagree Strongly
applicable N/A 5 4 3 2 disagree 1
5. Smoking is a bad example for my children.
Not applicable Strongly agree Somewhat agree Neutral Somewhat disagree Strongly disagree
N/A S 4 3 2 1
6. Smoking harms the health of my children.
Not Strongly agree Somewhat agree Neutral Somewhat disagree Strongly
applicable disagree
N/A 5 4 3 2 1
7. My family can better help me quit smo cing than a doctor, a priest or a quit
smoking program.
Not Strongly agree Somewhat agree Neutral Somewhat disagree Strongly
applicable N/A 5 4 3 2 disagree 1
8. I wou d discuss with my family my decision to quit smoking.
Not Strongly agree Somewhat agree Neutral Somewhat disagree Strongly
applicable N/A 5 4 3 2 disagree 1
9. I smoke with my family even when they do not smoke or are not smoking.
Not Strongly agree Somewhat agree Neutral Somewhat disagree Strongly
applicable N/A S 4 3 2 disagree 1
38


10. I smoke around children.
Not applicable Strongly agree Somewhat agree Neutral Somewhat disagree Strongly disagree
N/A S 4 3 2 1
11. My family wants me to quit smoking.
Not Strongly agree Somewhat agree Neutral Somewhat disagree 5 Strongly
applicable disagree
N/A 5 4 3 2 1
12. My family motivates me to quit smoking.
igNot Strongly agree Somewhat agree Neutral Somewhat disagree Strongly
applicable disagree
N/A 5 4 3 2 1
13. Quitting smoking would benefit the health of my fami y-
Not Strongly agree Somewhat agree Neutral Somewhat disagree Strongly
applicable disagree
N/A 5 4 3 2 1
14. When I choose to quit smoking, my family will help me.
Not Strongly agree Somewhat agree Neutral Somewhat disagree Strongly
applicable disagree
N/A 5 4 3 2 1
I
39


APPENDIX B
SPANISH QUESTIONNAIRE
SMOKING QUESTIONNAIRE
Date:________________________
S#;_______________ Researcher Initials:_____________ CO:.
EDAD:______
RAZA/ETNICIDAD:
DBlanco(a)
D Negro(a)/Africano(a) Americano(a)
D Hispano/Latino/Chicano
____Mexicano(a)
____Puertorriqueno(a)
____Dominicano(a)
____ de America Central
____Suramericano(a)
____Cubano(a)
D Indio de America
D de Asia
D Otro:________________
Genero:
D Femenino
Masculino
Estado Civil:
D Soltero(a)
D Casado(a)
D Divorciado(a)/Separado(a)
D Viudo(a)
40


Ponga un clrculo en el numero de anos de escuela que listed ha cumplido.
menos de 6 6 7 8 9 10 11 12 13 14 15 16 mas de
^.Cuanto gana en un ano?
$0 a $5,000 $20,000 a $25,000 $40,000 a $45,000
$5,000 a $10,000 $25,000 a $30,000 $45,000 a $50,000
$10,000 a $15,000 $30,000 a $35,000 D mas de $50,000
$15,000 a $20,000 $35,000 a $40,000
^Por cuanto tiempo ha vivido en los Estados Unidos?
^Por lo general, que idioma(s) lee y habla usted?
1 2 3 4 5
Solo Espanol mejor Ambos Ingles mejor Solo
Espanol que Ingles por igual que Espanol Ingles
^Cual fue el idioma(s) que hablo cuando era nino(a)?
1 2 3 4 5
Solo Mas Espanol Ambos Mas Ingles Solo
Espanol que Ingles por igual que Espanol Ingles
^Por lo general, en que idioma(s) habla en su casa?
1 2 3 4 5
Solo Mas Espanol Ambos Mas Ingles Solo
Espanol que Ingles por igual que Espanol Ingles
^Por lo general, en que idioma(s) piensa?
1 2 3 4 5
Solo Mas Espanol Ambos Mas Ingles Solo
Espanol que Ingles por igual que Espanol Ingles
41


^Por lo general en que idioma(s) habla con sus amigos(as)?
1 2 3 4 5
Solo Mas Espanol Ambos Mas Ingles Solo
Espanol que Ingles por igual que Espanol Ingles
^Por lo general, en que idioma(s) son las programas de television que usted ve??
1 2 3 4 5
Solo Mas Espanol Ambos Mas Ingles Solo
Espanol que Ingles por igual que Espanol Ingles
^Por lo general, en que idioma(s) son los programas de radio que usted escucha?
1 2 3 4 5
Solo Mas Espanol Ambos Mas Ingles Solo
Espanol que Ingles por igual que Espanol Ingles
^Por lo general, en que idioma(s) prefiere oir y ver pelfculas, y programas de radio y
television?
1 2 3 4 5
Solo Mas Espanol Ambos Mas Ingles Solo
Espanol que Ingles por igual que Espanol Ingles
Sus amigos y ami gas mas cercanos son:
1 2 3 4 5
Solo Latinos Mas Latinos Casi mitad Mas personas Solo personas que
que Personas y mitad que no son Latinos no son Latinos
que no Son Latinos que Latinos
Usted prefiere ir a reunfones sociales/fiestas en las cuales personas son:
1 2 3 4 5
Solo Latinos Mas Latinos Casi mitad Mas personas Solo personas que
que Personas y mitad que no son Latinos no son Latinos
que no Son Latinos que Latinos
42


Las personas que usted visita o que le vistan son:
1 2
Solo Latinos Mas Latinos
que Personas
que no Son Latinos
3 4 5
Casi mitad Mas personas Solo personas que
y mitad que no son Latinos no son Latinos
que Latinos
Si usted pudiera escoger los amigos(as) de sus hijos(as), quisiera que ellos(as) fueran:
1 2
Solo Latinos Mas Latinos
que Personas
que no Son Latinos
3 4 5
Casi mitad Mas personas Solo personas que
y mitad que no son Latinos no son Latinos
que Latinos
^Ha fumado usted por lo menos 100 cigarillos en su vida?
Sf
No
^Fuma usted cada dfa, algunos dfas, o ningun dfa?
D Cada dfa
D Algunos dfas
[] ningun dfa
^Por lo general, cuantos cigarillos esta fumando cada dfa?____
^Cuando fumo el ultimo cigarillo? Fecha:_____ Hora:___________
^Por cuantos anos ha fumado usted?_______
^Cuantos fumadores hay en su casa (no incluya a sf mismo)?______
^Cuanto tarda despues de despertarse en fumar su primer cigarillo?
D menos de 5 minutos
D entre 6 y 30 minutos
D entre 30 y 60 minutos
D despues de 60 minutos
43


^Encuentra diffcil abstenerse de fumar en sitios donde esta prohibido, tales como
iglesia, biblioteca, cine, etc.?
Si
No
lA que cigarillo odiaria mas renunciar?
D el primero del dfa
D cualquier otro
,-Fuma mas frecuentamente durante las primeras horas despues de despertarse que
durante el resto del dfa?
Si
No
^Fuma cuando esta tan enfermo que pasa en la cama la mayor parte del dfa?
Sf
No
^Cual de los siguentes describe su interes en dejando de fumar?
D Tengo planes de dejar de fumar en los promixos 30 dfas
D Tengo planes de dejar de fumar en los proximos 6 meses
D Tengo planes de dejar de fumar en el proximo ano
D Tengo planes de dejar de fumar algun dfa
D Du do que dejare
^Si ahora fuma, masca tobaco o usa snuffy quiere dejar, cuanta confianza tiene que
NO fumara, mascara tobaco o usara snuff en seis meses? Ponga un cfrculo en el
numero que mejor representa como Ud. siente.
12 345678 9 10
ninguna mucha
confianza confianza
44


Use la siguiente escala para indicar el envolvimiento de su familia en su decision de
dejar de fumar.
1. Mi fami ia influye mi decision de fumar.
No se aplica Muchisimo de acuerdo Mis o menos de acuerdo Neutral Mas o menos no de acuerdo
N/A 5 4 3 2
2. Mi fami ia tiene que ayudarme en dejar de fumar.
No se aplica Muchisimo de acuerdo Mas o menos de acuerdo Neutral Mas o menos no de acuerdo
N/A 5 4 3 2
3. Mi familia me apoyarfa en mi decision de dejar de fumar.
No se aplica Muchisimo de acuerdo Mas o menos de acuerdo Neutral Mas o menos no de acuerdo
N/A 5 4 3 2
4. Mi familia me apoyarfa en mi decision de seguir fumando.
No se aplica Muchisimo de acuerdo Mas o menos de acuerdo Neutral Mas o menos no de acuerdo
N/A 5 4 3 2
5. Fumar es mal ejemplo para mis ninos.
No se aplica Muchisimo de acuerdo Mis o menos de acuerdo Neutral Mas o menos no de acuerdo
N/A 5 4 3 2
6. Fumar le hace dano a la salud de mis ninos.
No se aplica Muchisimo de acuerdo Mas o menos de acuerdo Neutral Mas o menos no de acuerdo
N/A 5 4 3 2
Muchisimo no de
acuerdo
1
Muchisimo no de
acuerdo
1
Muchisimo no de
acuerdo
1
Muchisimo no de
acuerdo
1
Muchisimo no de
acuerdo
1
Muchisimo no de
acuerdo
1
7. Mi familia puede ayudarme mejor en dejar de fumar que un doctor, sacerdote o un
programa para dejar de fumar.
No se aplica N/A Muchisimo de acuerdo 5 Mas o menos de acuerdo 4 Neutral 3 Mas o menos no de acuerdo 2
8. Yo hablarfa con mi familia de mi decision de dejar c e fumar.
No se aplica Muchisimo de acuerdo Mas o menos de acuerdo Neutral Mas o menos no de acuerdo
N/A 5 4 3 2
Muchisimo no de
acuerdo
1
Muchisimo no de
acuerdo
1
9. Todavfa fumo con
mi familia cuando e
los no fuman o no estan fumando.
No se aplica Muchisimo de acuerdo Mas o menos de acuerdo Neutral Mas o menos no de acuerdo Muchisimo no de acuerdo
N/A S 4 3 2 1
45


10. Fumo cerca de ninos.
No se aplica Muchisimo de Mds o menos de Neutral Mds o menos no Muchisimo no de
acuerdo acuerdo de acuerdo acuerdo
N/A 5 4 3 2 1
11. Mi familia quiere que deje de fumar.
No se aplica Muchisimo de Mas o menos de Neutral Mds o menos no Muchisimo no de
acuerdo acuerdo de acuerdo acuerdo
N/A S 4 3 2 1
12. Mi farr lilia me motiva para dejar de fumar.
No se aplica Muchisimo de Mds o menos de Neutral Mds o menos no Muchisimo no de
acuerdo acuerdo de acuerdo acuerdo
N/A 5 4 3 2 X
13. Dejar c e fumar serfa beneficioso para la salud de mi familia.
No se aplica Muchisimo de Mds o menos de Neutral Mds o menos no Muchisimo no de
acuerdo acuerdo de acuerdo acuerdo
N/A 5 4 f #; 3 2 1
14. Cuando elija dejar de fumar, mi familia me ayudara.
Nose aplica Muchisimo de acuerdo Mds o menos de acuerdo Neutral Mds o menos no de acuerdo Muchisimo no de acuerdo
N/A 5 4 3 2 1
46


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