National Trends in Smoking Behaviors Among Mexican,Puerto Rican,and Cuban Men and Women in the United States

Objectives. We examined trends in smoking behaviors across 2 periods among Mexicans, Puerto Ricans, and Cubans in the United States.Methods. We analyzed data from the 1992–2007 Tobacco Use Supplements to the Current Population Survey. We constructed 2 data sets (1990s vs 2000s) to compare smoking behaviors between the 2 periods.Results. Significant decreases in ever, current, and heavy smoking were accompanied by increases in light and intermittent smoking across periods for all Latino groups, although current smoking rates among Puerto Rican women did not decline. Adjusted logistic regression models revealed that in the 2000s, younger Mexicans and those interviewed in English were more likely to be light and intermittent smokers. Mexican and Cuban light and intermittent smokers were less likely to be advised by healthcare professionals to quit smoking. Mexicans and Puerto Ricans who were unemployed and Mexicans who worked outdoors were more likely to be heavy smokers.Conclusions. Increases in light and intermittent smoking among Mexican, Puerto Rican, and Cuban Americans suggest that targeted efforts to further reduce smoking among Latinos may benefit by focusing on such smokers.Since 2000, Latinos have experienced the largest population growth of all US racial/ethnic groups, making Latinos the largest ethnic minority group in the country at 16.3% of the population.1 Mexicans, Puerto Ricans, and Cubans are the 3 largest Latino national and family background groups in the United States.1 The leading causes of death among Latinos are coronary heart disease and cancer, both of which are strongly associated with tobacco use.2,3 Although differences in smoking rates by Latino national origin groups have been found,4–6 very little research has examined trends in smoking behaviors for various Latino national origin groups by gender in the United States.The aggregation of smoking rates for various Latino national origin groups masks important variations within the population group.4 For example, smoking prevalence rates as determined by national data from 2008 are highest among Cubans (21.5%), followed by Mexicans (20.1%), and Puerto Ricans (18.6%).3 Puerto Ricans and Cubans are also more likely to be current smokers than are Mexicans.7 Furthermore, although research grounded on a nationally representative sample found that Latinos were approximately 4.5 times more likely to be light smokers than were non-Hispanic Whites,8 that study provided only aggregated rates for all Latinos and did not differentiate between national origin groups. Gender differences have also been reported among disaggregated Latino groups. A higher prevalence of smoking has been reported among Mexican (25.0%), Puerto Rican (27.6%), and Cuban (24.7%) men than among Mexican (10.4%), Puerto Rican (24.2%), and Cuban (12.4%) women.7 The lower rates of smoking among women have been consistent in surveys of Latinos.5,7,9 Results from these studies, although informative, have generally been determined by aggregated Latino data or data from a single survey time point. Although such data are valuable and can demonstrate existing gender differences, national-level trends from Latino nationality groups in the United States add valuable information that have not been previously reported.Previous research has also identified social and environmental factors associated with Latinos’ smoking behaviors. Acculturation to mainstream US culture plays a significant role in one’s health behaviors,10 and as Latinos acculturate, their smoking behaviors become similar to those of non-Hispanic Whites.7 Existing research has also revealed that Latinos are less likely to quit smoking,11 receive tobacco screening, and be advised to quit by a physician than are non-Hispanic Whites.12–15 A health professionals’ advice to quit smoking has been found to increase the likelihood that a smoker will successfully quit.16,17 Lastly, workplace smoking policies have also influenced smoking prevalence and intensity.18–20 Work environments adopting a smoke-free policy saw a 14% decrease in individuals’ smoking.21 When examining national-level smoking behaviors among Latinos, it is important to account for social and environmental factors such as acculturation, physician advice to quit smoking, and work environment smoking policies, as they may influence smoking behaviors.Existing research on smoking behaviors among Latino national origin groups has been predicated on data from specific regions of the United States.4,22–25 Although regional data are important for the development of community-level interventions,4 national-level data provide an overview of the country’s progress in tobacco control as well as remaining and emerging challenges for Latinos nationwide. We compared smoking behaviors across 2 periods, about a decade apart, among Mexicans, Puerto Ricans, and Cubans. Our goals in these analyses were (1) to compare Latino national origin groups across 2 periods to examine factors affecting changes in smoking behavior within and between groups, and (2) to evaluate demographic factors that influence current smoking behaviors within Latino national origin groups in the most recent period available. Examining long-term national trends in Latino smoking behaviors may prove vital to policymakers, public health officials, community workers, and interventionists as they address tobacco-related issues.     

Risk of Cigarette Smoking Initiation During Adolescence Among US-Born and Non–US-Born Hispanics/Latinos: The Hispanic Community Health Study/Study of Latinos

Objectives. We assessed risk of cigarette smoking initiation among Hispanics/Latinos during adolescence by migration status and gender.Methods. The Hispanic Community Health Study/Study of Latinos (HCHS/SOL) surveyed persons aged 18 to 74 years in 2008 to 2011. Our cohort analysis (n = 2801 US-born, 13 200 non–US-born) reconstructed participants’ adolescence from 10 to 18 years of age. We assessed the association between migration status and length of US residence and risk of cigarette smoking initiation during adolescence, along with effects of gender and Hispanic/Latino background.Results. Among individuals who migrated by 18 years of age, median age and year of arrival were 13 years and 1980, respectively. Among women, but not men, risk of smoking initiation during adolescence was higher among the US-born (hazard ratio [HR] = 2.10; 95% confidence interval [CI] = 1.73, 2.57; P < .001), and those who had resided in the United States for 2 or more years (HR = 1.47; 95% CI = 1.11, 1.96; P = .01) than among persons who lived outside the United States.Conclusions. Research examining why some adolescents begin smoking after moving to the United States could inform targeted interventions.Cigarette smoking and tobacco exposure account for nearly 500 000 deaths in the United States each year, or 20% of US deaths annually.1 Every day in the United States nearly 4000 people aged 12 to 17 years smoke their first cigarette, and about 1000 youths become daily cigarette smokers.2 People who begin smoking regularly during adolescence often become addicted by 20 years of age,3 which underscores the importance of examining risk factors for smoking initiation in adolescents. In 2012, the prevalence of cigarette smoking among Hispanic/Latino persons aged 12 to 17 years was estimated to be less than that of non-Hispanic Whites, but higher than among non-Hispanic Blacks and Asians.4 Among Hispanics/Latinos, 5% of youths aged 12 to 17 years, 25% of adults aged 18 to 25 years, and 17% of adults aged 26 years and older were current cigarette smokers.4Several studies have examined the association of cigarette smoking and birthplace among US Hispanics/Latinos. Most have reported a higher proportion of smokers among US-born than non–US-born Hispanics/Latinos, especially among women. One study found that the risk of smoking initiation was lower for Mexican immigrants who were living in the United States than for the same individuals before migration.5 Several others have suggested that exposure and acculturation to the US environment may increase cigarette smoking behavior in non–US-born populations.6–9 However, these studies did not focus specifically on adolescents.Few data exist on individuals from different Hispanic/Latino backgrounds. For instance, Puerto Ricans have a high smoking prevalence, are the second-largest group of US Hispanics/Latinos, and frequently migrate between the US mainland and the US territory of Puerto Rico.10 A recent study reported differences in smoking prevalence among adult Hispanics/Latinos by gender and background. For instance, men and women of Puerto Rican and Cuban descent had a higher prevalence of smoking than was found in national data on non-Hispanic Whites. Women of Mexican and Central American background had a lower smoking prevalence than other racial/ethnic groups in the United States.11 A combination of factors, including but not limited to migration to the United States, country or region of origin, and gender, likely affect risk of cigarette smoking initiation and persistence in Hispanics/Latinos.We assessed the association between migration and time to smoking initiation during adolescence and whether risk of smoking initiation increased with time since migration. We also assessed whether this association differed by gender and Hispanic/Latino background. The Hispanic Community Health Study/Study of Latinos (HCHS/SOL) provided data on large groups of Hispanics/Latinos of various ethnocultural backgrounds. HCHS/SOL participants were aged 18 to 74 years, but we were able to use questionnaire data to determine smoking history during adolescence. We hypothesized that the risk of cigarette smoking initiation during adolescence would be higher in US-born Hispanics/Latinos than in those born outside the 50 states and Washington, DC; that among individuals born outside the United States, this risk would increase with time since migration to the mainland United States; and that the risk of smoking initiation during adolescence might be modified by gender and Hispanic/Latino background. The HCHS/SOL cohort provided a unique opportunity to address this question in a heterogeneous group of Hispanics/Latinos and to compare associations across many different backgrounds.     

Race/Ethnicity and All-Cause Mortality in US Adults: Revisiting the Hispanic Paradox

Objectives. We examined the association between race/ethnicity and all-cause mortality risk in US adults and whether this association differs by nativity status.Methods. We used Cox proportional hazards regression to estimate all-cause mortality rates in 1997 through 2004 National Health Interview Survey respondents, relating the risk for Hispanic subgroup, non-Hispanic Black, and other non-Hispanic to non-Hispanic White adults before and after controlling for selected characteristics stratified by age and gender.Results. We observed a Hispanic mortality advantage over non-Hispanic Whites among women that depended on nativity status: US-born Mexican Americans aged 25 to 44 years had a 90% (95% confidence interval [CI] = 0.03, 0.31) lower death rate; island- or foreign-born Cubans and other Hispanics aged 45 to 64 years were more than two times less likely to die than were their non-Hispanic White counterparts. Island- or foreign-born Puerto Rican and US-born Mexican American women aged 65 years and older exhibited at least a 25% lower rate of dying than did their non-Hispanics White counterparts.Conclusions: The “Hispanic paradox” may not be a static process and may change with this population growth and its increasing diversity over time.Despite Hispanics’ lower socioeconomic position (i.e., lower education and income) and lower rate of health insurance coverage, they exhibit lower all-cause mortality rates than do non-Hispanics. This “Hispanic paradox” for adult mortality outcomes has been researched over the past 2 decades.1–12 Recent data for deaths in the United States show that the all-cause age-adjusted death rate for Hispanics (546.1/100 000) was much lower than were those for non-Hispanic Blacks (978.6) and Whites (763.3).13 Although this finding has also been reported by several studies,2–7,12,14 the mortality advantage for Hispanic subgroups is less well characterized. Results from studies examining the mortality advantage among Hispanic subgroups have been mixed, with some reporting lower rates2,3,5,6,10,12,14 and others reporting similar or higher rates for Hispanic subgroups compared with non-Hispanic Whites.5,6,12,14 A notable observation is that several of these studies simultaneously examined only Mexicans, Puerto Ricans, and Cubans.2,3,5,12Studies have also shown that compared with non-Hispanic Whites, the mortality advantage seems to be greater for foreign-born Hispanics than for their US-born counterparts.7,11,12,14–17 This advantage has been attributed to healthy in-migrant and unhealthy out-migrant selection effects,3,7,18 referred to as the “salmon bias hypothesis.”19 However, few studies examining the association between nativity status and mortality have focused on Hispanic subgroups, with 1 study focusing on Mexican Americans and other Hispanics14 and another on Mexican Americans, Puerto Ricans, Cubans, and other Hispanics.7 These studies suggested that the mortality advantage over non-Hispanic Whites may be specific to foreign-born Mexican Americans and other Hispanics.7,14 Therefore, given the continuous growth of the Hispanic population and its increasing heterogeneity regarding country of origin,20,21 studies focusing on Hispanic subgroups to examine this paradox are imperative.To contribute to the limited literature on the Hispanic paradox on all-cause mortality risk among Hispanic subgroups according to nativity status, we used data from the National Health Interview Survey (NHIS) for the years 1997 through 2004 linked to the National Death Index (NDI) mortality files to examine the association between race/ethnicity and all-cause mortality risk for US adults aged 25 years and older and whether this association differs by nativity status. For these analyses, the Hispanic category was defined using national origin or ancestry to specified subgroups as follows: Puerto Rican, Mexican, Mexican American, Cuban, Central and South American, and other Hispanic.     

A nationwide analysis of US racial/ethnic disparities in smoking behaviors, smoking cessation, and cessation-related factors

Objectives. We used nationally representative data to examine racial/ethnic disparities in smoking behaviors, smoking cessation, and factors associated with cessation among US adults.Methods. We analyzed data on adults aged 20 to 64 years from the 2003 Tobacco Use Supplement to the Current Population Survey, and we examined associations by fitting adjusted logistic regression models to the data.Results. Compared with non-Hispanic Whites, smaller proportions of African Americans, Asian Americans/Pacific Islanders, and Hispanics/Latinos had ever smoked. Significantly fewer African Americans reported long-term quitting. Racial/ethnic minorities were more likely to be light and intermittent smokers and less likely to smoke within 30 minutes of waking. Adjusted models revealed that racial/ethnic minorities were not less likely to receive advice from health professionals to quit smoking, but they were less likely to use nicotine replacement therapy.Conclusions. Specific needs and ideal program focuses for cessation may vary across racial/ethnic groups, such that approaches tailored by race/ethnicity might be optimal. Traditional conceptualizations of cigarette addiction and the quitting process may need to be revised for racial/ethnic minority smokers.Racial/ethnic minorities in the United States experience a disproportionate burden of smoking-related diseases, including cancer and heart disease, despite having larger proportions of light and intermittent smokers and generally lower adult smoking prevalence rates than non-Hispanic Whites.^1–3 Racial/ethnic minorities are also less likely to quit smoking successfully than are non-Hispanic Whites.^4–8 For example, rates of successful smoking cessation among African American smokers are lower than they are among non-Hispanic Whites, despite reports citing lower cigarette consumption.^2,5,7,9 Similarly, Hispanics/Latinos do not experience higher rates of successful quitting than non-Hispanic Whites, despite being more likely to be light and intermittent smokers.^2,9 There is currently no evidence indicating that Asian Americans quit at higher rates than non-Hispanic Whites in the United States.¹⁰ The examination of racial/ethnic disparities in smoking behaviors, successful quitting, and factors associated with quitting can provide valuable information for focusing strategies for groups currently experiencing lower rates of successful smoking cessation, and can lead to decreases in smoking-related disease rates across all racial/ethnic populations.Previous research on population-level data has found several factors to be associated with successful smoking cessation. For example, banning smoking in one''s home can greatly increase the chances of successfully quitting smoking. The presence of a complete ban on smoking in one''s home is associated with being quit for at least 90 days¹¹ and with being a former smoker.¹² However, an analysis of national data found that smaller percentages of non-Hispanic Whites (64.0%) and African Americans (64.4%) have a complete home smoking ban than do Hispanics/Latinos (78.0%) and Asian Americans/Pacific Islanders (79.2%).¹³ Being advised to quit smoking by health care professionals, especially physicians, has also been associated with increased rates of smoking cessation.^14–17 Despite progress in smokers being advised to quit by health care practitioners in the past 5 years, African American and Hispanic/Latino smokers remain less likely than non-Hispanic Whites to be advised to quit.^16,18 Finally, although evidence of the effectiveness of nicotine replacement therapy (NRT) at the population level has been challenged recently,^19,20 there is evidence that NRT can aid successful cessation.^17,21–23 There is substantial evidence that racial/ethnic minorities are less likely to be prescribed NRT^14,15,18 and to use NRT to quit smoking.^23–25The Tobacco Use Supplements to the Current Population Surveys (TUS-CPS) have provided invaluable data for the examination of various smoking-related issues at the national level.^11,13 In 2003, the TUS-CPS included a special supplement that focused heavily on smoking cessation. This supplement was the first TUS-CPS with this focus (and is the only one to date), and it provides arguably the richest representative national-level data on smoking cessation in the United States. This special supplement thus presented a unique opportunity to examine in detail the disparities between racial/ethnic groups in smoking cessation and important related factors.For our study, we hypothesized the following: (1) African Americans would experience less success in quitting smoking than would non-Hispanic Whites, (2) Asian Americans/Pacific Islanders and Hispanics/Latinos would be more likely to have a complete home smoking ban than would non-Hispanic Whites, (3) African Americans and Hispanics/Latinos would be less likely than would non-Hispanic Whites to report being advised by a health professional to quit smoking, and (4) racial/ethnic minorities would be less likely to use NRT than would non-Hispanic Whites.To examine these hypotheses, we conducted a secondary data analysis of the 2003 TUS-CPS to assess smoking cessation rates and examine how factors associated with successful smoking cessation differed across racial/ethnic groups among adults in the United States. Findings from this report may provide insight into optimal design of targeted smoking cessation interventions for members of specific racial/ethnic groups.     

Exploring Migratory Dynamics on HIV Transmission: The Case of Mexicans in New York City and Puebla,Mexico

Migration and population movement are increasingly viewed as important factors associated with HIV transmission risk. With growing awareness of the potential impact of migration on HIV transmission, several perspectives have emerged that posit differing dynamics of risk. We considered available data on the role of migration on HIV transmission among Mexican migrants in New York City and Puebla, Mexico. Specifically, we examined 3 distinct models of migratory dynamics of HIV transmission—namely, the structural model, the local contextual model, and the interplay model. In doing so, we reframed current public health perspectives on the role of migration on HIV transmission.The epidemiological literature related to Latinos and HIV in the United States highlights geographic disparities in disease burden.1 HIV/AIDS cases among Latinos are clustered geographically, such that Latinos experience increased vulnerability as a function of residence in high-risk physical and geographic areas.2 Recent trends in HIV infection demonstrate that Latino mobility and migratory patterns are potentially associated with increased HIV incidence.3 As a result, several key dynamics to account for the role of migration and HIV transmission have emerged in recent literature. However, to adequately address the current HIV epidemic among Latinos, greater consideration of each of these mechanisms and enhanced attention to the role of geography and migration is warranted.4 Recent findings increasingly draw attention to the role of population mixing and movement, geography, and other physical spaces as important factors for understanding Latino HIV disparities.5 We build upon this work by examining the available empirical literature on HIV and migration in relation to the social structures and contexts in which risk behavior takes place. Specifically, we explored 3 mechanisms for the impact of migration on HIV transmission through the case of Mexican migrants in New York City (NYC) and Puebla.As the epicenter of the HIV/AIDS epidemic in the United States, NYC is one such high-risk geographic area.6 New York City has an incidence rate 3 times the national average and the highest number of AIDS cases relative to any other metropolitan city.6 Latinos in the city are disproportionately affected by the disease and are twice as likely to be diagnosed with HIV/AIDS compared with non-Hispanic Whites.7 Furthermore, although Latinos account for approximately 25% of the population in NYC, they represent 33% of NYC persons living with HIV/AIDS (PLWHA).8,9 Among NYC Latinos, HIV occurs primarily among adults through high-risk sexual behavior and intravenous drug use.10 Specifically, Latino men who have sex with men (MSM) constitute the majority of cases (40%), followed by injection drug users (27%).10 These data suggest that in NYC, Latino MSM and intravenous drug users bear the burden of HIV disease. However, a significant proportion of Latina women in NYC infected with HIV are exposed through high-risk sexual activity (67%) and represents a steady proportion of new HIV diagnoses among women in recent years.11HIV/AIDS is of particular concern among Latinos as they are more likely to experience delays in access to care, which results in adverse health outcomes. For example, Latinos, particularly Mexicans with low levels of acculturation, are less likely to obtain an HIV test.12 Those who are diagnosed often experience rapid progression to AIDS, suggesting that many Latinos are diagnosed late in their infection.6 In 2011, for example, 31% of Latinos diagnosed with HIV in NYC were concurrently diagnosed with AIDS, compared with only 15% of Whites.11 Late diagnosis puts Latinos at greater health risks because they do not receive the benefits of early antiretroviral treatment.13 In addition to late diagnosis and delayed treatment, obstacles in access to HIV treatment for Latinos include lack of a designated routine health care provider and adequate health insurance.14Increasingly, the Latino population in NYC has undergone important demographic changes.15 Specifically, migratory changes have shifted the composition of the Latino population in NYC, introducing new Latino subgroups to a geographic area of heightened HIV risk. Traditionally, the Latino population in NYC has been classified as largely stemming from the Caribbean—specifically, Puerto Rico and the Dominican Republic. However, Mexicans, whose US migration patterns have traditionally been associated with the areas of the Southwest, are increasingly moving to NYC, a nontraditional receiving community.For example, the Mexican population in NYC in 2010 was more than 5 times what it was in 1990.16 In 1990, an estimated 56 700 Mexicans were living in NYC; by 2000, this number grew to 180 000, and later to 325 000 in 2010.16 Foreign-born males with less than a high-school education represent the bulk of the Mexican population growth and a significant portion of this population attains employment in NYC.15 By 2024, it is predicted that Mexicans will be the most populous Latino ethnic subgroup in the largest city of the United States.17 One notable feature of NYC’s Mexican community is that nearly half (45%) originates from the state of Puebla in east-central Mexico, although other sources suggest far higher proportions (more than 70%).18 Data from the American Community Survey demonstrate that Mexican-born persons are geographically clustered in specific target communities, predominantly the Bronx and Queens (Figure 1).19Open in a separate windowFIGURE 1—Foreign-born from Mexico by Public Use Microdata Areas in New York City: 2006–2008.Note. PUMA = Public Use Microdata Area.Source. US Census Bureau.20     

Allostatic Load in Foreign-Born and US-Born Blacks: Evidence From the 2001–2010 National Health and Nutrition Examination Survey

Objectives. We tested whether the immigrant health advantage applies to non-Hispanic Black immigrants and examined whether nativity-based differences in allostatic load exist among non-Hispanic Blacks.Methods. We used pooled data from the 2001–2010 National Health and Nutrition Examination Survey to compare allostatic load scores for US-born (n = 2745) and foreign-born (n = 152) Black adults. We used multivariate logistic regression techniques to assess the association between nativity and high allostatic load scores, controlling for gender, age, health behaviors, and socioeconomic status.Results. For foreign-born Blacks, length of stay and age were powerful predictors of allostatic load scores. For older US-born Blacks and those who were widowed, divorced, or separated, the risk of high allostatic load was greater.Conclusions. Foreign-born Blacks have a health advantage in allostatic load. Further research is needed that underscores a deeper understanding of the mechanisms driving this health differential to create programs that target these populations differently.There is growing interest in improving population health because Healthy People 2020 and the Patient Protection and Affordable Care Act include important provisions to reduce health disparities.1,2 Recent research suggests that certain racial/ethnic groups in the United States, particularly non-Hispanic Blacks, have higher rates of morbidity and all-cause mortality than do Whites. However, non-Hispanic Blacks are a heterogeneous group that includes a growing population of immigrants from a variety of countries and cultural backgrounds. Recent estimates suggest the foreign-born segment of the Black population has almost tripled over the past 3 decades—with the majority migrating from the Caribbean and Africa—and represents roughly 8% of the Black population.3,4 Despite this marked increase, little is known about the health of foreign-born Blacks.Previous research suggests that Caribbean and African immigrants differ from their US-born counterparts in various physical5–8 and mental health indicators.9 Some research suggests that foreign-born Blacks have better health outcomes than do US-born Blacks because of the healthy immigrant effect.10,11 The healthy immigrant effect posits that immigrants have healthier lifestyles in their home countries, are among the healthiest from their home country, and are the group most willing and able to endure the stressors associated with immigration, therefore placing them at a health advantage. However, the health advantage declines with increased time spent in the United States, as immigrants adapt to the US sociocultural environment.10 Research suggests Caribbean and African immigrants have worse health over time because they have higher levels of psychological stress related to immigration and adjusting to new sociocultural environments.9 Additionally, the impact of exposure to racism in the United States may be particularly stressful for immigrants from regions of the world where they were a demographic majority.8,9To measure the deleterious effects of stress on the body, the concept of allostatic load has been introduced as a unique approach to understanding the underlying biological processes that might explain health vulnerability. Allostatic load accounts for the cumulative impact of physiological responses to acute, chronic, or long-term psychosocial stressors generated by social conditions that continuously activate hormonal responses to stressful conditions. Prolonged activation of these physiological systems is thought to place persons at risk for the development for both physical and mental disorders.12,13 The literature on allostatic load suggests that overexposure to adverse conditions while adapting to US culture can create a buildup of stressors endemic to the immigrant experience, particularly for immigrants of color.Some studies document the deleterious effects for foreign-born populations of psychosocial stress on the body and dysregulation of physiological systems known to protect the individual from disease.14 Much of this research has focused on Hispanics, partly because they are one of the largest immigrant ethnic groups, there is available survey data, and there is scientific interest in the Hispanic health paradox.15,16 This paradox—that Hispanics exhibit better health outcomes than do non-Hispanic Whites despite their lower than expected socioeconomic status—has been challenged in various studies in which time in the United States has been shown to be the predictor that is most associated with health declines.17 Kaestner et al.18 found that with increased time in the United States, the probability of having a high allostatic load score increased for foreign-born Mexicans. Peek et al.19 reported that among foreign-born Mexicans, those who had lived in the United States for more than 10 years were more likely to have high allostatic load scores. In this way, allostatic load offers a viable reason for the health decline among immigrants but has not been extensively studied in foreign-born Black populations.The only study to investigate the association between allostatic load and chronic health conditions for a population of Latinos that can identify themselves as Black or of African descent20 found that increasing allostatic load scores were significantly associated with abdominal obesity, hypertension, diabetes, self-reported cardiovascular disease, and arthritis for Puerto Ricans.21 However, to our knowledge, no study has examined the relationship between nativity and allostatic load among US- and foreign-born Blacks. Testing this hypothesis will provide knowledge about whether allostatic load operates in a similar way for this understudied population as evidenced in the Latino immigrant literature. We used the 2001–2010 National Health and Nutrition Examination Survey (NHANES)—one of the largest surveys designed to assess the health and nutritional status of adults residing in the United States—to examine nativity-based differentials in allostatic load. On the basis of previous research on immigrant health, we expected to observe a health advantage in allostatic load for foreign-born over US-born Blacks similar to what has been documented in studies focused on Mexican-born individuals.     

Community Poverty and Trends in Racial/Ethnic Survival Disparities Among People Diagnosed With AIDS in Florida, 1993–2004

Objectives. We described the racial/ethnic disparities in survival among people diagnosed with AIDS in Florida from 1993 to 2004, as the availability of highly active antiretroviral therapy (HAART) became widespread. We determined whether these disparities decreased after controlling for measures of community-level socioeconomic status.Methods. We compared survival from all causes between non-Hispanic Blacks and non-Hispanic Whites vis-a-vis survival curves and Cox proportional hazards models controlling for demographic, clinical, and area-level poverty factors.Results. Racial/ethnic disparities in survival peaked for those diagnosed during the early implementation of HAART (1996–1998) with a Black-to-White hazard ratio (HR) of 1.72 (95% confidence interval [CI] = 1.62, 1.83) for males and 1.40 (95% CI = 1.24, 1.59) for females. These HRs declined significantly to 1.48 (95% CI = 1.35, 1.64) for males and nonsignificantly to 1.25 (95% CI = 1.05, 1.48) for females in the 2002 to 2004 diagnosis cohort. Disparities decreased significantly for males but not females when controlling for baseline demographic factors and CD4 count and percentage, and became nonsignificant in the 2002 to 2004 cohort after controlling for area poverty.Conclusions. Area poverty appears to play a role in racial/ethnic disparities even after controlling for demographic factors and CD4 count and percentage.The HIV/AIDS epidemic has disproportionately affected the non-Hispanic Black population in the United States. In 2008, an estimated 545 000 non-Hispanic Blacks were living with HIV/AIDS.1 The estimated prevalence of HIV infection for 2008 among non-Hispanic Blacks was 18.2 per 1000 population, more than 7 times higher than the estimated rate for non-Hispanic Whites (non-Hispanic Whites; 2.4 per 1000).1 Non-Hispanic Blacks as a group not only have a higher prevalence of HIV/AIDS, but once infected also have a lower survival rate. The 3-year survival rate in the United States for people diagnosed with AIDS between 2001 and 2005 was 80% among non-Hispanic Blacks compared with 84% for non-Hispanic Whites, 83% for Hispanics, and 88% for Asians,2 further contributing to the disparities in the HIV mortality rate of 16.8 per 100 000 among non-Hispanic Blacks compared with 1.6 per 100 000 among non-Hispanic Whites during 2007.3 Race/ethnicity is a fundamentally social as opposed to a biological construct,4,5 and survival disparities between non-Hispanic Blacks and non-Hispanic Whites have not generally been seen in settings with universal health care access such as in the Veterans Administration health care system,6 the military health care system,7 or a health maintenance organization.8 Therefore, potentially modifiable social explanations for the observed racial/ethnic disparities in survival should be examined.A most remarkable advance in medical treatment in the past century was the development of highly active antiretroviral therapy (HAART). It led to a significant improvement in survival from HIV/AIDS, 9–12 but racial/ethnic disparities in HIV/AIDS survival remain2, 13–16 and in New York City appeared to widen.17 Despite these well-recognized health disparities, there is a critical gap in the knowledge about why the disparity exists. Two population-based studies, both in San Francisco, California (a city that has provided free HIV care for those who cannot afford it), found that Black race was no longer associated with survival between 1996 and 2001 after controlling for neighborhood socioeconomic status (SES), and that this SES effect seemed to be related to HAART use.18,19 However, in a study using HIV surveillance data from 33 states, racial/ethnic disparities in 5-year survival after HIV diagnosis between 1996 and 2003 persisted after adjusting for county-level SES and other factors.20 The objective of this study was to describe the racial/ethnic disparities in AIDS survival in Florida among people diagnosed with AIDS between 1993 and 2004 (a period spanning the time before and during the widespread availability of HAART) and to determine if these disparities decrease after controlling for community-level SES.     

A Cross-National Study on Prevalence of Mental Disorders,Service Use,and Adequacy of Treatment Among Mexican and Mexican American Populations

Objectives. We examined differences in the use of mental health services, conditional on the presence of psychiatric disorders, across groups of Mexico’s population with different US migration exposure and in successive generations of Mexican Americans in the United States.Methods. We merged surveys conducted in Mexico (Mexican National Comorbidity Survey, 2001–2002) and the United States (Collaborative Psychiatric Epidemiology Surveys, 2001–2003). We compared psychiatric disorders and mental health service use, assessed in both countries with the Composite International Diagnostic Interview, across migration groups.Results. The 12-month prevalence of any disorder was more than twice as high among third- and higher generation Mexican Americans (21%) than among Mexicans with no migrant in their family (8%). Among people with a disorder, the odds of receiving any mental health service were higher in the latter group relative to the former (odds ratio = 3.35; 95% confidence interval = 1.82, 6.17) but the age- and gender-adjusted prevalence of untreated disorder was also higher.Conclusions. Advancing understanding of the specific enabling and dispositional factors that result in increases in mental health care may contribute to reducing service use disparities across ethnic groups in the United States.Epidemiological studies have found that migration from Mexico to the United States is associated with a dramatic increase in psychiatric morbidity. Risk for a broad range of psychiatric disorders, which is relatively low in the Mexican general population, is higher among Mexican-born immigrants in the United States and higher still among US-born Mexican Americans.1–5 Risk among US-born Mexican Americans is similar to that of the non-Hispanic White population.6 Recent research suggests that the association between migration and mental health extends into Mexico, where return migrants and family members of migrants are at higher risk for substance use disorders than those with no migrant in their family.3,7Little is known about the influence of cultural and social changes associated with migration on the use of mental health services. As the mental health system is much more extensive8 and use of mental health service is much more common9 in the United States than in Mexico, we expect that Mexican Americans would use mental health services more frequently than their counterparts in Mexico. However, it is not known whether the increase in service use keeps pace with the increase in prevalence of psychiatric disorders. Moreover, in the United States, Hispanics in general and Mexican Americans in particular are less likely to receive mental health services than are non-Hispanic Whites,10–12 and immigrants are less likely to use mental health services than the US born, particularly if they are undocumented.13We made use of a unique data set formed by merging surveys conducted in Mexico and the United States that used the same survey instrument. We used these data to examine differences in past-year mental health service use, conditional on the past-year prevalence of psychiatric disorder, associated with migration on both sides of the Mexico–US border.     

Pathways and Correlates Connecting Latinos' Mental Health With Exposure to the United States

Objectives. We examined potential pathways by which time in the United States may relate to differences in the predicted probability of past-year psychiatric disorder among Latino immigrants as compared with US-born Latinos.Methods. We estimated predicted probabilities of psychiatric disorder for US-born and immigrant groups with varying time in the United States, adjusting for different combinations of covariates. We examined 6 pathways by which time in the United States could be associated with psychiatric disorders.Results. Increased time in the United States is associated with higher risk of psychiatric disorders among Latino immigrants. After adjustment for covariates, differences in psychiatric disorder rates between US-born and immigrant Latinos disappear. Discrimination and family cultural conflict appear to play a significant role in the association between time in the United States and the likelihood of developing psychiatric disorders.Conclusions. Increased perceived discrimination and family cultural conflict are pathways by which acculturation might relate to deterioration of mental health for immigrants. Future studies assessing how these implicit pathways evolve as contact with US culture increases may help to identify strategies for ensuring maintenance of mental health for Latino immigrants.It has been shown that Latino immigrants have better mental health than their US-born counterparts and non-Latino Whites, despite having disadvantaged socioeconomic status^1–3 (the “immigrant paradox”). It has also been shown that the mental health of immigrants declines over time in the host country³ (the “acculturation hypothesis”). Our findings from the National Latino and Asian American Study (NLAAS) on the prevalence of psychiatric disorders among Latinos in the United States indicate that foreign nativity is protective for some Latino groups (e.g., Mexicans) but not others (e.g., Puerto Ricans),⁴ implying that other factors besides nativity play a part in US Latinos'' risk of psychiatric disorders. Also, there is evidence that risk of psychopathology is the result of differences in immigrants'' length of residence in the United States and age at arrival. For example, Mexican immigrants in the United States for 13 years or more had higher rates of any mental health disorder, any mood disorder, alcohol abuse, and drug abuse than Mexican immigrants in the United States for fewer than 13 years.³ Findings from the NLAAS indicate that the longer that Latino immigrants remain in their country of origin, the less cumulative risk of onset of psychiatric disorders they experience, resulting in lower lifetime rates of disorders.⁵There is a lack of consensus about which aspects of US exposure are relevant for mental health.⁵ A number of hypotheses have linked years in the United States and mental illness among Latinos.³ US-born Latinos may have a weaker affiliation with traditional Latino values that buffer against mental illness than do Latino immigrants. When individuals come into contact with US culture, there may be negative outcomes such as increased intergenerational conflict,⁶ augmenting their risk for psychopathology. Although family factors have been hypothesized to be a protective factor for immigrant Latinos,^7,8 few empirical studies have actually tested this hypothesis with regard to psychiatric disorders. Another hypothesis is that US-born Latinos may have higher expectations for their quality of life than immigrant Latinos because of their citizenship status and their acquisition of skills similar to those possessed by non-Latino Whites.⁹ However, over time, these expectations may remain unfulfilled because of discrimination, resulting in social stress and declining levels of mental health.¹ Also, as time passes, immigrants may have perceptions of low social status¹⁰ that may be associated with higher risk of psychopathology.Other immigration-related factors could also affect adaptation experiences when integrating into the United States. Specifically, those arriving in the United States at early formative ages (0–10 years) may have weaker identification with Latino cultural values¹¹ and may confront significant pressure to acquire English as their dominant language.¹² English language dominance represents a strong cultural anchor for socially constructed meaning¹³ that may enable immigrants to join certain peer networks and not others. The neighborhoods where Latinos typically live are less safe than those inhabited by non-Latino Whites,¹⁴ which may increase Latinos'' likelihood of psychiatric disorders¹⁵ by increasing ambient hazards. In addition, exposure to racial/ethnic based discrimination^16,17 has been associated with negative mental health outcomes. The NLAAS study provides a unique opportunity to explore these pathways because these domains have been assessed for both Latino immigrants and US-born Latino respondents.We assessed the association of time in the United States with past-year risk for psychiatric disorder, with and without adjustment for potentially influential covariates. Then we tested different pathways explaining the link between time in the United States and psychiatric disorders.     

Loose Cigarette Purchasing and Nondaily Smoking Among Young Adult Bar Patrons in New York City

Objectives. We examined loose cigarette (loosie) purchasing behavior among young adult (aged 18–26 years) smokers at bars in New York City and factors associated with purchase and use.Methods. Between June and December 2013, we conducted cross-sectional surveys (n = 1916) in randomly selected bars and nightclubs. Using multivariable logistic regression models, we examined associations of loose cigarette purchasing and use with smoking frequency, price, social norms, cessation behaviors, and demographics.Results. Forty-five percent (n = 621) of nondaily smokers and 57% (n = 133) of daily smokers had ever purchased a loosie; 15% of nondaily smokers and 4% of daily smokers reported that their last cigarette was a loosie. Nondaily smokers who never smoked daily were more likely than were daily smokers to have last smoked a loosie (odds ratio = 7.27; 95% confidence interval = 2.35, 22.48). Quitting behaviors and perceived approval of smoking were associated with ever purchasing and recently smoking loosies.Conclusions. Loosie purchase and use is common among young adults, especially nondaily smokers. Smoking patterns and attitudes should be considered to reduce loose cigarette purchasing among young adults in New York City.Widespread adoption of clean indoor air laws and cigarette tax increases denormalize smoking behavior1 and decrease smoking rates.2,3 Although increasing taxes is one of the most effective means of smoking prevention and reduction,3 the increased price of cigarettes can also lead to tax-avoidant behaviors, such as buying untaxed packs smuggled from states with lower cigarette taxes and purchasing loose cigarettes, or “loosies.”4–6 In New York City (NYC), where a cigarette pack costs about $11.50, it has become common for smokers to purchase discounted packs and individual cigarettes from street peddlers and friends.7,8Much of the research exploring loosie purchasing in the United States has focused on underage or low-income minority populations, often in urban areas.7,9,10 One study found that in early 1993, 70% of stores in central Harlem sold loosies to minors.7 Another study conducted with a 2005–2006 convenience sample in inner-city Baltimore found that 77% of African American smokers aged 18 to 24 years had purchased loosies in the past month.11 Similarly, loosie purchasing in Mexico was more common among younger smokers with lower incomes.12Availability and visibility of loosies can promote smoking and encourage relapse.13 We defined nondaily smokers as those who smoked on 1 to 29 of the past 30 days.14,15 Shiffman et al. found that nondaily smokers were more likely than daily smokers to report that social and environmental stimuli motivated their smoking behavior.16 More specifically, cues such as taste, smell, social goading to smoke, and specific situations (e.g., smoking after meals) are more likely to be reported as motivators to smoke by nondaily smokers than by daily smokers.16 Because social–environmental cues have substantial impact on nondaily smokers’ motivation to smoke, it is likely that the cue of seeing loosies in one’s environment also motivates nondaily smokers to smoke.16Previous research substantiates this claim, with 1 study showing that people who regularly saw loosies available for purchase were more likely to be current smokers.17 Therefore, the widespread availability of loosies may have a greater impact on nondaily smokers. Nondaily smokers make up a third of US smokers,18,19 and nondaily smoking is increasingly common among young adults.20 Many young adults who smoke on only some days do not self-identify as smokers,21 and nondaily smoking is frequently paired with alcohol consumption.22–24 Nondaily and light smoking carry a lower, but substantial, risk for lung cancer and a similar risk as does daily smoking for cardiovascular disease.25–27 Occasional smokers also have higher smoking-related morbidity and mortality than do people who have never smoked.26,28–30Nondaily smoking can be a long-term behavior pattern31,32 or a transition to or from daily smoking.31 Nondaily smokers include different subgroups that may have very different smoking patterns or motivations to quit.33,34 Nondaily smokers who previously smoked daily have been defined in previous research as converted nondaily smokers. Nondaily smokers who have never smoked daily are defined as native nondaily smokers.18,19 Important differences exist between these subgroups of smokers: converted nondaily smokers are more likely to quit smoking than are native nondaily smokers and daily smokers,18,19 although most converted and native nondaily smokers were unable to remain abstinent for more than 90 days.19Loosie purchasing and use may play an important role in promoting continued tobacco use among nondaily smokers. The 2010 NYC Community Health Survey35 found that more than one third (34%) of young adult nondaily smokers (aged 18–26 years) reported that their last cigarette smoked was a loosie, compared with 14% of young adult daily smokers. Another study of NYC adults demonstrated that nondaily smokers were more likely to purchase loose cigarettes than were light and heavy smokers.36 To the best of our knowledge, little is known about the factors associated with loosie purchasing among nondaily smokers in the United States.We sought to better understand the factors associated with loosie purchasing among NYC young adults, specifically to determine (1) loosie purchase and use rates among converted nondaily, native nondaily, and daily smokers; (2) whether loosie purchase or use are associated with perceived social norms of smoking behavior; and (3) whether loosie purchasing is associated with smoking cessation intention or behavior.     

Hispanic Men in the United States: Acculturation and Recent Sexual Behaviors With Female Partners, 2006–2010

Objectives. We examined Hispanic men’s recent risky and protective sexual behaviors with female partners by acculturation.Methods. Using the 2006–2010 National Survey of Family Growth, we performed bivariate analyses to compare acculturation groups (Hispanic Spanish-speaking immigrants, Hispanic English-speaking immigrants, Hispanic US natives, and non-Hispanic White men) by demographics and recent sexual behaviors with women. Multivariable logistic regression models for sexual behaviors by acculturation group were adjusted for demographics.Results. Compared with Hispanic Spanish-speaking immigrants, non-Hispanic White men were less likely to report exchange of money or drugs for sex (adjusted odds ratio [AOR] = 0.3; 95% confidence interval [CI] = 0.1, 0.9), but were also less likely to report condom use at last vaginal (AOR = 0.6; 95% CI = 0.4, 0.8) and anal sex (AOR = 0.4; 95% CI = 0.3, 0.7). Hispanic US natives were less likely to report condom use at last vaginal sex than were Spanish-speaking immigrants (AOR = 0.6; 95% CI = 0.4, 0.8). English- and Spanish-speaking immigrants did not differ in risky or protective sexual behaviors.Conclusions. Our findings suggest that targeted interventions focusing on unique sexual risks and sociodemographic differences by acculturation level, particularly nativity, may be helpful for preventing sexually transmitted infections.In the United States, Hispanics are one of the subpopulations disproportionately affected by sexually transmitted infections (STIs).1 In 2010, reported cases of chlamydia were 2.7 times higher for Hispanics than for non-Hispanic Whites.1 Similarly, primary and secondary syphilis cases were 2.2 times higher for Hispanics than for non-Hispanic Whites, an increase of 9.5% since 2009.1 Reported gonorrhea rates were also 2.2 times higher for Hispanics than for non-Hispanic Whites. Regarding gender, the racial/ethnic disparity in gonorrhea rates was higher for men (48.7 per 100 000 for Hispanics vs 19.5 per 100 000 for non-Hispanic Whites) than for women (51.1 per 100 000 for Hispanics vs 26.6 per 100 000 for non-Hispanic Whites).1 Among young adult men (18–26 years), STI disparities were even greater; among Hispanic men, the prevalence of chlamydia and gonorrhea was 5.3 and 4.1 times higher than for non-Hispanic White men, respectively.2Research has shown that Hispanics face many unique challenges that increase their risks for STIs, including immigration-related challenges, living apart from their spouse or regular partner, language barriers, racism, social isolation, and limited access to health care.1,3–5 Compared with non-Hispanic Whites, Hispanics often also have higher poverty, unemployment, and high school dropout rates, and are younger.1,4,6 From 2000 to 2010, the Hispanic population in the United States increased by more than 15.2 million (an increase of 43%), contributing to half of the total population growth in the country.7 Because of the growing Hispanic population, the disproportionate burden of STIs, and the numerous barriers and challenges increasing their risk for STIs, an assessment of the sexual behaviors of Hispanics, including risk and protective behaviors, are of public health importance.An epidemiological concept known as the Hispanic paradox posits that health outcomes for Hispanics tend to be more similar to those of non-Hispanic Whites than those of non-Hispanic Blacks because of less acculturation, or “Americanization,” among Hispanics, which has been shown to be associated with lower sexual risk behaviors and better health outcomes.8–10 Some research suggests that the Hispanic paradox is variable and fluid or may not exist at all.11,12 Although many studies have examined the relationship between acculturation and sexual risk behaviors that are related to STI transmission, most of this research has focused on Hispanic women, adolescents, or men who have sex with men.13–22 Fewer studies have examined differences among Hispanic men in their sexual behaviors with female partners in terms of acculturation group. One study found that low-income, recent-immigrant Hispanic men (living in the United States less than 5 years) were more likely to commercially exchange sexual services and less likely to have a main sex partner than established immigrants (living in the United States for more than 5 years).23 Conversely, established Hispanic immigrant men were more likely to report unprotected sexual intercourse and multiple sex partners than recent immigrants.23 For protective behaviors, condom use at last sex did not significantly differ by acculturation among Hispanic men, although condom use is positively associated with acculturation for women.18,24,25 All of these studies were restricted to specific local areas.Acculturation of Hispanics has been measured in many ways—the use of a single variable, a combination of variables, or scales developed to capture the various aspects of acculturation. Complex measures of acculturation include attitudinal and behavioral factors focused on cultural values.10 More intricate scales of acculturation include heritage and mainstream scales with measures of attitude, behavior, and social relations.10,26 However, it is difficult to include comprehensive measures of acculturation in national surveys that have limited space and competing interests. Measures such as language, country of origin, nativity, and length of time in the country are considered proxy measures of acculturation.11,13,19,27–29 The most frequently used variable to measure acculturation is language of interview (English or Spanish) or the language spoken at home.3,13,14,17,19,21,22,24,27–33 Although acculturation is a multifaceted concept, research suggests that language preference may be a reliable proxy for more complex acculturation measures of Hispanics living in the United States.17For an examination of differences in Hispanic men’s sexual behaviors with female partners by level of acculturation, a national-level examination is useful given the diversity of the Hispanic population in the United States, where origin (Mexican, Puerto Rican, Cuban, Central American, etc.) differs by geography.34 Using data from a national survey, we analyzed the recent sexual behaviors of acculturation groups of Hispanic men (categorized by language of interview and nativity) and compared them with those of non-Hispanic White men. Specifically, we sought to examine differences in recent risky and protective sexual behaviors with female partners among acculturation groups using the 2006–2010 National Survey of Family Growth (NSFG).     

Impact of Alcohol Use and Bar Attendance on Smoking and Quit Attempts Among Young Adult Bar Patrons

Objectives. We examined cigarette smoking and quit attempts in the context of alcohol use and bar attendance among young adult bar patrons with different smoking patterns.Methods. We used randomized time location sampling to collect data among adult bar patrons aged 21 to 26 years in San Diego, California (n = 1235; response rate = 73%). We used multinomial and multivariate logistic regression models to analyze the association between smoking and quit attempts and both drinking and binge drinking among occasional, regular, very light, and heavier smokers, controlling for age, gender, race/ethnicity, and education.Results. Young adult bar patrons reported high rates of smoking and co-use of cigarettes and alcohol. Binge drinking predicted smoking status, especially occasional and very light smoking. All types of smokers reported alcohol use, and bar attendance made it harder to quit. Alcohol use was negatively associated with quit attempts for very light smokers, but positively associated with quitting among heavier smokers.Conclusions. Smoking and co-use of cigarettes and alcohol are common among young adult bar patrons, but there are important differences by smoking patterns. Tobacco interventions for young adults should prioritize bars and address alcohol use.Tobacco is responsible for approximately 443 000 deaths in the United States annually,1,2 but cessation before the age of 30 years avoids most of the long-term health consequences of smoking.3 As smoking prevalence has declined,4 nondaily smoking and low-level daily cigarette consumption,5–7 also referred to as occasional or light smoking patterns, have increased.8–11 Nondaily smokers made up 4.1% of the US adult population in 2006,12 increasing from 3.2% in 1997 and 1998.6 Nondaily smokers accounted for 19.9% of current smokers in 2006,12 increasing from 16.0% in 1997 and 1998.6 Younger age is associated with occasional smoking,9,13 and nondaily smoking is common among young adults. In 1997 and 1998, 5.5% of young adults aged 18 to 24 years were nondaily smokers, accounting for 19.9% of young adult smokers, the highest proportion of nondaily smoking among all age groups.6Alcohol complicates occasional or light smoking in young adults, and it often plays a powerful catalyst role in facilitating and maintaining smoking.14 Young adults report that alcohol increases the enjoyment of and desire for cigarettes,15,16 and tobacco enhances the desired effect of alcohol.17–19 The co-use of cigarettes and alcohol has been described as like “milk and cookies” or “peanut butter with jelly.”20The co-use of tobacco and alcohol among young adults15,21,22 poses a serious health threat. Use of both cigarettes and alcohol increases the risk for certain cancers (e.g., mouth, throat, esophagus, upper aerodigestive tract)23–25 and makes it more difficult to quit either substance.26–28 In a 2001–2002 national study, 2.9% of adults aged 18 years and older (6.2 million) reported both alcohol use disorders and a dependence on nicotine by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, and young adults aged 18 to 24 years exhibited the highest rates of this comorbidity.22Bars and nightclubs are key public venues where young adults congregate and use both alcohol and tobacco. Tobacco companies have targeted young adults, using entertaining events to reinforce a smoker-friendly atmosphere in bars and nightclubs.16,29–31 Many tobacco marketing events have encouraged alcohol use by offering alcohol discounts, paraphernalia, or by holding alcohol drinking contests.16,29,30,32 The strong rewarding effects of nicotine paired with alcohol,33–35 the aggressive tobacco marketing linked with alcohol,32 and the peer acceptance of smoking while drinking at parties in bars and nightclubs20 have put young adult bar patrons at high risk for tobacco use and co-use of tobacco and alcohol, even for occasional and light smokers.To our knowledge, no study has examined the co-use of tobacco and alcohol among young adult bar patrons. This is a hard-to-reach population often underrepresented in national surveillance studies. Additionally, no study has assessed co-use behavior among young adult occasional and light smokers, an increasingly common behavior. We examined patterns of smoking and quit attempts in the context of alcohol use and bar attendance among 4 groups of young adult smokers attending bars in San Diego, California, including occasional, regular, very light, and heavier smokers.     

The Health Benefits of Hispanic Communities for Non-Hispanic Mothers and Infants: Another Hispanic Paradox

Objectives. In the United States, Hispanic mothers have birth outcomes comparable to those of White mothers despite lower socioeconomic status. The contextual effects of Hispanic neighborhoods may partially explain this “Hispanic paradox.” We investigated whether this benefit extends to other ethnic groups.Methods. We used multilevel logistic regression to investigate whether the county-level percentage of Hispanic residents is associated with infant mortality, low birth weight, preterm delivery, and smoking during pregnancy in 581 151 Black and 2 274 247 White non-Hispanic mothers from the US Linked Birth and Infant Death Data Set, 2000.Results. For White and Black mothers, relative to living in counties with 0.00%–0.99% of Hispanic residents, living in counties with 50.00% or more of Hispanic residents was associated with an 80.00% reduction in the odds of smoking, an infant mortality reduction of approximately one third, and a modest reduction in the risks of preterm delivery and low birth weight.Conclusions. The health benefits of living in Hispanic areas appear to bridge ethnic divides, resulting in better birth outcomes even for those of non-Hispanic origin.The US Hispanic population is predicted to double by 2050, by which time it will constitute nearly one third of the total US population.1 In the process, the characteristics of many communities will change, and this has potential implications for public health. Neighborhood socioeconomic context and many other characteristics of communities, such as the physical environment and social cohesion, are known to have an impact on the health of residents.2–5The US Hispanic population has rates of infant mortality and low birth weight (LBW) that are comparable to those of non-Hispanic US Whites6 despite Hispanic mothers being more likely to live in socioeconomically deprived areas and to have low socioeconomic status.7 This well-known phenomenon is termed the “Hispanic paradox.”8 Potential explanations for it include the selective migration of healthy women,8 social support and access to kin networks,9 and the promotion of healthier behaviors in Hispanic cultures.10 Recent research also suggests that high Hispanic density, that is, a high proportion of Hispanic residents in a community, is associated with better pregnancy outcomes (lower infant mortality and higher birth weight) and lower pregnancy smoking rates for Hispanics, regardless of their individual socioeconomic status or health-related behaviors.11–13Explanations offered for these protective effects of Hispanic density include the ideas that Hispanic neighborhoods may act as enclaves that protect people from stigma and prejudice,14,15 may increase social support, and may lower communication costs because of the shared culture and language.13 Interestingly, US-born mothers of Hispanic origin receive greater reductions in risk of infant mortality11 and smoking during pregnancy12 from living in areas of high Hispanic density than do immigrant mothers. Similarly US-born mothers of Mexican origin have been shown to have infants with lower rates of LBW when they live in immigrant enclaves.13 Second- or later-generation Hispanic mothers are generally more acculturated and more likely to adopt the social and cultural norms of the dominant society instead of, or in addition to, the culture of their ethnic origin.16 Thus it appears that the benefits of living in Hispanic communities may be strongest for US-born Hispanic mothers. This raises the question of whether the salutary benefits of living in Hispanic communities are restricted to those of Hispanic heritage or whether they extend to other ethnic groups living in those communities.The only studies we are aware of that have investigated the impact of Hispanic density on birth outcomes among non-Hispanic and multiethnic population samples focused on birth weight. Morenoff found that, after adjusting for each individual resident’s ethnicity, there was a nonsignificant positive association of the percentage of Mexican Americans living in Chicago, Illinois, neighborhood clusters with higher birth weight for mothers of all ethnicities.17 By contrast, Masi et al.18 found that higher Hispanic density measured at the level of census tracts in Chicago had an adverse association with birth weight and risk of preterm birth for White but not Black mothers, and Peak and Weeks19 found that the proportion of Hispanic residents in census block groups was associated with an increased risk of LBW for non-Hispanic White mothers living in San Diego, California. The limited evidence so far suggests that living in communities with higher proportions of Hispanic people might be associated with reduced risk of some, but not all, maternal and infant health outcomes for some non-Hispanics in some places.We previously examined the impact of Hispanic density on Hispanic maternal and infant health using a nationally representative sample from the US Linked Birth and Infant Death Data Set, 2000.12 We found that Hispanic mothers living in US counties with a higher Hispanic density had lower rates of infant mortality and smoking during pregnancy but limited evidence of associations with LBW and preterm birth. We investigated whether these demonstrated benefits of Hispanic density are transmitted to other ethnic groups. Specifically, we examined whether non-Hispanic White and non-Hispanic Black residents in counties with high Hispanic density have lower risks of infant mortality, LBW, preterm delivery, and maternal smoking during pregnancy than did their counterparts living in counties with low-Hispanic density.     

US Cultural Involvement and Its Association With Suicidal Behavior Among Youths in the Dominican Republic

Objectives. We examined how US cultural involvement related to suicide attempts among youths in the Dominican Republic.Methods. We analyzed data from a nationally representative sample of youths attending high school in the Dominican Republic (n = 8446). The outcome of interest was a suicide attempt during the past year. The US cultural involvement indicators included time spent living in the United States, number of friends who had lived in the United States, English proficiency, and use of US electronic media and language.Results. Time lived in the United States, US electronic media and language, and number of friends who had lived in the United States had robust positive relationships with suicide attempts among youths residing in the Dominican Republic.Conclusions. Our results are consistent with previous research that found increased risk for suicide or suicide attempts among Latino youths with greater US cultural involvement. Our study adds to this research by finding similar results in a nonimmigrant Latin American sample. Our results also indicate that suicide attempts are a major public health problem among youths in the Dominican Republic.There is growing evidence that US nativity increases risk for suicide ideation, suicide attempts, and death by suicide for Latino youths and adults. Foreign-born Latinos have lower rates of completed suicide compared with US-born Latinos across several national and regional cohorts.^1–3 Moreover, rates for suicide ideation or attempts among foreign-born or less acculturated Latinos have been lower than those of their US-born counterparts.^4–7The phenomenon of immigrant Latinos having better health outcomes than US-born Latinos has been referred to by various names, including the healthy immigrant effect, the Latino paradox, and the epidemiological paradox. Moreover, this trend has been found for numerous outcomes.⁸ A number of models have been proposed to explain this finding including cultural protective factors associated with Latino culture,^9,10 discrepancies in intergenerational values between immigrant parents and their US-born children,¹¹ and selection bias related to immigration of healthier or more resilient individuals.^12,13 Methodological constraints have unfortunately limited the ability to test determinants that could explain these differences. One constraint that has limited the ability to test the selection bias hypothesis has been the scarcity of comparable data from “feeder” nations that provide US Latino immigrant populations.In one of the few studies that used cross-national data, Mexican youths in high schools near the US–Mexico border reported lower rates of suicide ideation than Mexican American youths in high schools on the US side of the border.¹⁴ In another study using a binational (United States and Mexico) sample of Mexicans, US-born Mexicans and Mexican-born immigrants who arrived in the United States when aged 12 years or younger had higher rates of suicide ideation than Mexicans without a history of migration to the United States or a family member living there. Mexicans with family members living in the United States and US-born Mexicans were also at higher risk for suicide attempts.¹⁵ These findings do not support the selection bias explanation for nativity differences in suicide behaviors among adults or youths of Mexican ancestry living in the United States. Although the literature suggests that Latinos share certain core panethnic cultural values such as familism and respect,^16–18 the peoples of Latin America have distinct historical, social, immigration, and cultural contexts. It is therefore prudent to test, validate, or disprove explanatory mechanisms such as immigration selection bias across different Hispanic subgroups.One variation on the approach of using data from feeder countries is to examine how US cultural involvement may relate to risk for suicidal behavior within a non–US setting via mechanisms related to “cultural globalization.” Cultural globalization parallels the process known as economic globalization and refers to the penetration of cultural influences (e.g., US cultural influence) on the lifestyles, values, norms, and retention of cultural heritage in youths around the world.^19,20 The strength of this approach is that it examines the relationship between US cultural influence and suicidal behavior in a nonimmigrant Latino population.The Dominican Republic (DR)—because of its large US-based population,²¹ relatively close proximity to the United States, and historical connections to the United States^22,23—offers an excellent natural experiment to test whether US cultural influence relates to outcomes such as suicide risk behaviors among youths. For example, there are approximately 1.3 million Dominicans living in the United States,²¹ compared with a relatively modest population of approximately 10 million Dominicans living in the Dominican Republic.²⁴ This ratio of US Dominicans to DR Dominicans makes possible several mechanisms for how cultural globalization in the Dominican Republic may occur, especially as it relates to US cultural influence. The first, circular migration, has been conceptualized and operationalized in multiple ways. We use a literal definition: leaving and then returning to a country of origin, once or repeatedly. Circular migration is often driven by immigrants’ economic circumstances, legal status, and US labor market demands.²⁵ Another mechanism for US cultural influence in the Dominican Republic occurs through ties that Dominicans have with relatives, friends, or acquaintances who live in the United States or who have lived in the United States. The US cultural influence in the Dominican Republic also occurs indirectly via the influences of electronic media such as US-based movies, television, and music.We examined how US cultural involvement indicators relate to suicide attempts among a nationally representative sample of public high school students in the Dominican Republic. We focused on suicide behavior because it has been identified as a growing worldwide public health concern for youths and young adults.^26,27 Moreover, suicide attempts are associated with hospitalization, future attempts,²⁸ and future death by suicide.^29,30 Despite prevalent concern about adolescent suicide attempts, little is known about the epidemiology of suicide behaviors in the Dominican Republic.To our knowledge, this is the first study to publish data on suicide attempts among DR youths that used a nationally representative sample. However, in one unpublished report that used data from a national sample of DR youths attending public school in 1997, as many as 7.9% of the youths reported a suicide attempt during the past year.³¹ This rate is on par with the 7.7% of youths who reported a suicide attempt during that same year in the United States, but lower than the 10.7% of US Hispanics who reported a suicide attempt in 1997.³² These rates for suicide behavior represent a public health problem among youths in the Dominican Republic. This study will add to the literature by publishing results related to suicide attempts among DR youths in a nationally representative sample and by increasing knowledge regarding the healthy immigrant effect pertaining to suicide attempts. On the basis of the robust associations found between suicide behaviors and US involvement among US Latino and Mexican populations, we hypothesized that greater US cultural involvement would increase risks for suicide attempts among DR youths.     

e-Cigarette Awareness,Use, and Harm Perceptions in US Adults

Objectives. We estimated e-cigarette (electronic nicotine delivery system) awareness, use, and harm perceptions among US adults.Methods. We drew data from 2 surveys conducted in 2010: a national online study (n = 2649) and the Legacy Longitudinal Smoker Cohort (n = 3658). We used multivariable models to examine e-cigarette awareness, use, and harm perceptions.Results. In the online survey, 40.2% (95% confidence interval [CI] = 37.3, 43.1) had heard of e-cigarettes, with awareness highest among current smokers. Utilization was higher among current smokers (11.4%; 95% CI = 9.3, 14.0) than in the total population (3.4%; 95% CI = 2.6, 4.2), with 2.0% (95% CI = 1.0, 3.8) of former smokers and 0.8% (95% CI = 0.35, 1.7) of never-smokers ever using e-cigarettes. In both surveys, non-Hispanic Whites, current smokers, young adults, and those with at least a high-school diploma were most likely to perceive e-cigarettes as less harmful than regular cigarettes.Conclusions. Awareness of e-cigarettes is high, and use among current and former smokers is evident. We recommend product regulation and careful surveillance to monitor public health impact and emerging utilization patterns, and to ascertain why, how, and under what conditions e-cigarettes are being used.A heterogeneous collection of battery-driven nicotine inhalers—“e-cigarettes” or electronic nicotine delivery systems (ENDS)—are emerging products receiving considerable advocacy, policy, and media attention.1 ENDS have been marketed as harm-reducing alternatives to smoking and used as cessation aids, though the US Food and Drug Administration (FDA) has not reviewed these claims or devices.2,3 Independent testing of ENDS has demonstrated poor quality control,2,4 low-level toxic contaminants,5 variable nicotine delivery,2,6,7 and insufficient evidence of overall public health benefit.8 Packaging and Web sites for ENDS reveal unsubstantiated health claims and erroneous nicotine content labeling.4 In addition, their wide combination of flavorings and “high-tech” image are potentially attractive to youths and young adults.2,4 In 2010, the World Health Organization recommended that ENDS products be regulated as combination drug and medical devices.1 Consistent with this recommendation, several countries, such as Australia and Canada, restricted or banned ENDS until reviewed by their regulatory agencies.9,10 A 2009 court decision (Sottera Inc v. Food and Drug Administration)11 blocked the FDA from regulating ENDS as drug delivery devices in the United States, ruling that products containing nicotine derived from tobacco are “tobacco products” under the 2009 Family Smoking Prevention and Tobacco Control Act unless they are sold as therapeutic aids for cessation.12 In keeping with this ruling, on April 25, 2011, the FDA announced its intention to regulate ENDS as tobacco products. The nature of the FDA’s ENDS regulation procedure has yet to be determined; until that time, ENDS will likely continue to be sold to consumers without regulation, raising serious concerns for public health.Although variations of ENDS have been on the market since at least 2007,13 little is known about the population prevalence of ENDS use in representative samples. One study examined Google searches and reported a sharp increase from 2008 to 2010 in queries, with ENDS search terms receiving more hits than nicotine patches and snus.14 Although this suggests relative increased interest, the denominators are unknown. In a European study, Etter et al.15 posted a survey in French for 34 days on a cessation Web site (http://www.stop-tabac.ch), which typically obtains about 120 000 visitors a month. Of 214 respondents, 81 eligible ENDS users reported mainly using ENDS for cessation or to avoid disturbing others; some were concerned about potential ENDS toxicity.16 Another online survey17 of first-time ENDS purchasers yielded a response proportion of only 4.5%; considering this low percentage, participants are not likely representative of ENDS purchasers and results are difficult to interpret. In a 2009 Zogby opinion poll, 59% of Americans supported FDA regulation of ENDS, with almost half (47%) saying that ENDS should be made available for people who want to quit smoking.18There are several widely cited and as yet unaddressed concerns regarding the effect of ENDS on public health. First is the concern that ENDS could act as a starter product for combustible cigarettes, especially among youths or young adults who may be attracted to their “tech” image or flavorings.3,19 Other concerns include that ENDS may lure former smokers to return to nicotine dependence, delay cessation among current smokers,2,3 serve as a dual-use product, or enable individuals to avoid smoking restrictions.19 Despite these gaps in our knowledge, there are no reliable national estimates of ENDS awareness, utilization, or harm perceptions in the peer-reviewed literature. Furthermore, other than the 2009 Zogby poll, no investigation of ENDS among nonsmokers is evident.18 This study makes an initial contribution to address some of these pressing knowledge gaps by using cross-sectional data from 2 separate surveys conducted in 2010, 1 nationally representative and 1 from the follow-up of a large cohort of current smokers and recent former smokers, to estimate ENDS awareness, use, and harm perceptions in the adult US population.     

Mexican American Trial of Community Health Workers: A Randomized Controlled Trial of a Community Health Worker Intervention for Mexican Americans With Type 2 Diabetes Mellitus

Objectives. We assessed whether community health workers (CHWs) could improve glycemic control among Mexican Americans with diabetes.Methods. We recruited 144 Mexican Americans with type 2 diabetes between January 2006 and September 2008 into the single-blinded, randomized controlled Mexican American Trial of Community Health Workers (MATCH) and followed them for 2 years. Participants were assigned to either a CHW intervention, delivering self-management training through 36 home visits over 2 years, or a bilingual control newsletter delivering the same information on the same schedule.Results. Intervention participants showed significantly lower hemoglobin A1c levels than control participants at both year 1 Δ = −0.55; P = .021) and year 2 (Δ = −0.69; P = .005). We observed no effect on blood pressure control, glucose self-monitoring, or adherence to medications or diet. Intervention participants increased physical activity from a mean of 1.63 days per week at baseline to 2.64 days per week after 2 years.Conclusions. A self-management intervention delivered by CHWs resulted in sustained improvements in glycemic control over 2 years among Mexican Americans with diabetes. MATCH adds to the growing body of evidence supporting the use of CHWs to reduce diabetes-related health disparities.The growing prevalence of diabetes mellitus among adults in the United States is well documented, with adverse impact strongest among ethnic minorities and low-income populations. The age-adjusted prevalence of diabetes is 12.6% among non-Hispanic Blacks, 11.8% among Hispanics, and only 7.1% among non-Hispanic Whites.1 Mexican Americans, who make up almost two thirds of US Hispanics,2 have an even higher diabetes prevalence of 13.3%.3 Disparities also persist in both processes of care and clinical outcomes. Mexican Americans with diabetes are significantly less likely than non-Hispanic Whites with the disease to be aware of and treated for comorbid hypertension or dyslipidemia.4 Mexican Americans are less likely to receive recommended clinical services, such as regular ophthalmologic and foot exams,5 and are less likely than non-Hispanic Whites to have well-controlled hemoglobin A1c (HbA1c) and cholesterol levels. In this context, it is not surprising that they are more than twice as likely as non-Hispanic Whites to be hospitalized for uncontrolled diabetes or long-term complications of diabetes5 and that they experience higher diabetes mortality rates.6–8 Although non-Hispanic Whites have experienced reductions in diabetes-related mortality in the past decades, Hispanics have not.8 Thus, unless effective public health strategies are identified and implemented, gaps in health outcomes are likely to grow.Community health workers (CHWs) are frontline public health workers who serve as liaisons between providers and community members, facilitate access to services, and improve both quality and cultural competence of service delivery.9,10 Several characteristics suggest that they may be well suited to addressing diabetes disparities. Because CHWs share culture, language, and knowledge of the community, they engage minority populations more effectively than the formal health care system can.11,12 Living and working in the same community as the people they serve, CHWs are able to provide individualized attention, focus on behavior-related tasks, and deliver regular feedback on the completion of those tasks.13 These qualities should lead to improved diabetes self-management and clinical outcomes. Although much has been written about CHWs in the past decade, few rigorous randomized controlled trials have tested this hypothesis,14–18 and the efficacy of CHWs in improving clinical outcomes in diabetes is not established. Of 6 published randomized controlled trials,19–25 only 2 demonstrated improvements in HbA1c levels among intervention participants, and both of these studies followed participants for only 6 months.19,24 Methodological limitations led the authors of a 2009 Agency for Health Care Research and Quality review to rate the published evidence as fair at best.15The Mexican American Trial of Community Health Workers (MATCH) sought to address these limitations of the literature through a rigorously designed behavioral randomized controlled trial with outcomes measured at 1 and 2 years. The primary study hypothesis was that the CHW intervention, compared with an attention control, would result in improvement in short-term physiological outcomes (mean HbA1c levels and percentage with controlled blood pressure). A secondary hypothesis was that the CHW intervention would improve adherence to self-management behaviors, such as daily self-monitoring of blood glucose, medication taking, and adherence to diet and physical activity recommendations.     

Discrimination and Substance Use Disorders Among Latinos: The Role of Gender,Nativity, and Ethnicity

Objectives. We examined the relationship between discrimination and substance use disorders among a diverse sample of Latinos. We also investigated whether the relationship between discrimination and substance use disorders varied by gender, nativity, and ethnicity.Methods. Our analyses focused on 6294 Latinos who participated in the National Epidemiologic Survey on Alcohol and Related Conditions from 2004 to 2005. We used multinomial logistic regression to examine the association between discrimination and substance use disorders.Results. Discrimination was significantly associated with increased odds of alcohol and drug use disorders among Latinos. However, the relationship between discrimination and substance use disorders varied by gender, nativity, and ethnicity. Discrimination was associated with increased odds of alcohol and drug use disorders for certain groups, such as women, US-born Latinos, and Mexicans, but this relationship did not follow the same pattern for other subgroups.Conclusions. It is important to determine which subgroups among Latinos may be particularly vulnerable to the negative effects of discrimination to address their needs.Latinos are the largest ethnic or racial minority group in the United States1 and the fastest growing group entering substance abuse treatment programs.2 Although Latinos are disproportionately affected by substance abuse,3 they have been understudied.4 Previous research shows that high levels of poverty, minority status, and residential concentration in areas with widespread drug and alcohol distribution have been considered to be factors that may put Latinos at risk for substance use disorders.5 More recently, discrimination has also been considered to be a risk factor.6,7 As studies aim toward filling the gap in the literature, the heterogeneity of Latinos must also be considered.Discrimination has been associated with alcohol and drug use8–13 and substance use disorders among Latinos.6,7 Stress-coping frameworks and the minority stress model have been applied to hypothesize that individuals belonging to various marginalized groups respond to experiences of discrimination with unhealthy coping behaviors, such as substance use.14,15 Moreover, discrimination may lead to underemployment, lower wages, and limited access to health services and other resources that can affect health outcomes.16 In this way, discrimination operates at both the interpersonal and institutional levels simultaneously to situate individuals on different health trajectories, fostering and reinforcing poor health behaviors and outcomes.16,17The association between discrimination and substance use has been previously documented for Latinos and other groups. However, reviews of the literature have called for more granular analysis of specific risk patterns. One specific area needing analysis is whether some subgroups of Latinos are at higher risk of substance use related to discrimination than others. The identification of subgroups is an important first step toward the development of targeted population-level approaches and tailored interventions.In the present study, we focused on subgroups based on gender, nativity, and ethnicity (country of origin or heritage country). These subgroups were based on ascribed characteristics that refer to immutable characteristics (vs achieved characteristics, such as education) that are given status value.18,19 The status value placed on these characteristics can drive discrimination; for example, when men are considered more valuable than women and when US-born individuals are considered more valuable than immigrants.18,19 At the same time, these characteristics (gender, nativity, and ethnicity) are also associated with substance use disorders.Gender differences in substance use disorders are not unique to Latinos. Across racial/ethnic groups, men consistently have higher prevalence of substance use disorders. Using data from the National Latino and Asian American Study, the lifetime prevalence of alcohol use disorders was 16.7% for Latino men and 4.3% for Latina women.20 Research also shows that Latino men generally reported higher levels of discrimination compared with Latina women.13,21 Data from the National Latino and Asian American Study showed that 39% of Latino men, compared with 29% of Latina women, reported discrimination.22 These authors suggested that these patterns might be the result of minority men being more exposed and vulnerable to racial bias from social institutions. These higher rates of substance use and discrimination among men also appeared to be jointly related. A recent study found that discrimination was associated with increased risk of drug abuse among Latino men, but not Latina women.6 This interaction might occur because of greater cultural acceptability among men overall to use substances to cope with stress compared with women. In contrast, women were found to rely on social support and to turn to food to cope with stress.23–25 Other specific factors, such as abuse history,26 were found to be more central in predicting risk of substance use disorders among Latina women. Thus, we expected that discrimination would have a stronger relationship with substance use disorders among Latino men than Latina women.Similar to health differences by gender, differences by nativity are not unique to Latinos. Overall, foreign-born individuals tend to be healthier than their US-born counterparts. Lifetime rates of substance use disorders were higher among US-born than foreign-born Latinos (19.6% vs 5.5%, respectively).20 Previous studies also found greater reporting of discrimination among US-born Latinos; 47% of US-born compared with 25% of foreign-born Latinos reported discrimination.22 However, discrimination might be more harmful to foreign-born Latinos because they are less likely to enjoy citizenship rights (e.g., voting privileges, access to educational scholarships) that might help temper some of the stressful effects of discrimination. From this perspective, we expected that discrimination would have a stronger relationship with substance use disorders among foreign-born than US-born Latinos.Finally, it is also important to consider ethnicity. There is some indication of variation in rates of substance use across these groups. Cubans were found to have lower odds of substance use disorders compared with Puerto Ricans.27 In addition, there was good evidence for variation in reporting of discrimination.28 For example, 40% of Puerto Ricans reported discrimination compared with 34% of Mexicans and 16% of Cubans.22 This variation might be attributed to gradations based on socioeconomic resources that differ by Latino ethnicity.29 Gradations based on socioeconomic resources could dictate the risks and resources individuals have exposure and access to, affecting coping mechanisms. Thus, we expected the relationship between discrimination and substance use disorders to vary by ethnicity as well.In sum, based on this literature, we hypothesized that discrimination would be associated with increased risk of substance use disorders among Latinos overall, and that the relationship between discrimination and substance use disorders would vary by ascribed characteristics. Specifically, we theorized that the relationship between discrimination and substance use disorders would be stronger among men compared with women, among foreign-born Latinos compared with US-born Latinos, and among Mexicans and Puerto Ricans compared with Cubans.     

Race,Ethnicity, and Self-Reported Hypertension: Analysis of Data From the National Health Interview Survey, 1997–2005

Objective. I estimated the association between race and self-reported hypertension among Hispanics and non-Hispanics and determined whether this association was stronger among non-Hispanics.Methods. With data from the 1997–2005 National Health Interview Survey, I used logistic regression to estimate the strength of the association between race/ethnicity and self-reported hypertension among US adults.Results. The overall prevalence of self-reported hypertension was 24.5%, with lower prevalence among Hispanics (16.7%) than among non-Hispanics (25.2%; P < .01). Blacks, regardless of ethnicity, had the highest prevalence. Compared with non-Hispanic Whites, non-Hispanic Blacks had 48% (odds ratio [OR] = 1.48; 95% confidence interval [CI] = 1.41, 1.55) greater odds of reporting hypertension; Hispanic Whites had 23% (OR = 0.81; 95% CI = 0.76, 0.88) lower odds. There was no difference in the strength of the association between race and self-reported hypertension observed among non-Hispanics (OR for Blacks = 1.47) and among Hispanics (OR for Blacks = 1.20; for interaction, P = 0.43).Conclusions. The previously reported hypertension advantage of Hispanics holds for Hispanic Whites only. As Hispanics continue their rapid growth in the United States, race may have important implications on their disease burden, because most US health disparities are driven by race and its socially patterned experiences.Hypertension affects more than 65 million US adults¹ and is a major risk factor for cardiovascular disease (CVD).^2,3 The prevalence of hypertension in the US population increased by 30% between the third National Health and Nutrition Examination Survey (NHANES III, 1988–1994) and NHANES 1999–2000.¹ Previous studies have consistently reported that, compared with non-Hispanic Whites, Hispanics have a lower prevalence of hypertension and that non-Hispanic Blacks have a higher prevalence of hypertension.^1,2,4–7 However, these studies focused mostly on Mexican Americans, ignoring the heterogeneity of the Hispanic population. For example, because of their colonization patterns, Hispanics can be of any race (i.e., White, Black, or some other race).⁸ Despite the impact of race on health in US society^9–11 and the projected growth of the Hispanic population,^12–14 there is a dearth of knowledge addressing the relationship between race and health among Hispanics. However, the evidence that does exist parallels findings observed among non-Hispanics: Hispanic Blacks experience worse health outcomes than do Hispanic Whites.^15–18 Thus, the investigation of race and health outcomes in Hispanics is imperative.Hypertension has been attributed to obesity, sodium and potassium intake, physical inactivity, alcohol consumption, smoking, and psychosocial stress.³ Of these, only psychosocial stress has been shown to be unequally distributed across racial/ethnic groups. Research suggests that racial discrimination—a trigger of psychosocial stress—is common in the everyday life of non-Hispanic Blacks and may lead to CVD.^19–26 Given this, and consistent with the historical pattern of disadvantage among non-Hispanic Blacks,^9,11,27,28 it is possible that Hispanic Blacks could be exposed to the same deleterious experiences of racial discrimination and racism as non-Hispanic Blacks because of the salience and social visibility associated with their race or dark skin color. These experiences may lead to disadvantaged life chances, which then translate into poorer health.The availability of 9 years of data from the National Health Interview Survey (NHIS, 1997–2005) afforded the opportunity to investigate the association between race and self-reported hypertension in Hispanics and non-Hispanics before and after adjustment for selected characteristics and known risk factors and to compare the strength of this association in Hispanics and non-Hispanics. If race as a social construct channels Hispanic Blacks to exposures detrimental to health as it does for non-Hispanic Blacks, the lower odds of hypertension for Hispanics observed in previous studies would apply only to Hispanic Whites whereas Hispanic Blacks would have odds of hypertension similar to those of non-Hispanic Whites or intermediate between non-Hispanic Whites and non-Hispanic Blacks. However, the magnitude of the association between race and hypertension would be stronger among non-Hispanics than among Hispanics.