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This Article Abstract Full Text (PDF) Spanish Abstract All Versions of this Article: AJPH.2006.095505v1 97/11/2040    most recent Submit a response View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Detjen, M. G. Articles by Chasan-Taber, L. Search for Related Content PubMed PubMed Citation Articles by Detjen, M. G. Articles by Chasan-Taber, L. Related Collections Other Maternal and Infant Health Hispanics/Latinos Women's Health Tobacco Control

M. Gabrielle Detjen, MS, F. Javier Nieto, MD, PhD, Amy Trentham-Dietz, PhD, Michael Fleming, MD and Lisa Chasan-Taber, ScD

M. Gabrielle Detjen, F. Javier Nieto, and Amy Trentham-Dietz are with the Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison. Michael Fleming is with the Department of Family Medicine, School of Medicine and Public Health, University of Wisconsin, Madison. Lisa Chasan-Taber is with the Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts, Amherst.

Correspondence: Requests for reprints should be sent to M. Gabrielle Detjen, University of Wisconsin, School of Medicine and Public Health, 748 WARF Office Building, 610 Walnut St, Madison, WI 53726 (e-mail: mgdetjen{at}wisc.edu).

	ABSTRACT

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

 

Objectives. We explored whether higher levels of acculturation were associated with higher rates of cigarette smoking among pregnant Hispanic women residing in the United States.

Methods. We evaluated data from the Latina Gestational Diabetes Mellitus Study, a prospective study of 1231 Hispanic prenatal care patients conducted from 2000 to 2004 in Massachusetts. Self-reported data on acculturation, cigarette smoking, and covariates were collected by bilingual interviewers using a questionnaire. We conducted logistic regression multivariate analyses to examine the impact of acculturation level on the odds of smoking.

Results. Overall, 21% of women reported smoking during pregnancy. Acculturation was associated with elevated smoking rates in pregnant Hispanic women. US-born Hispanic women who preferred English had more than twice the odds of smoking compared with Puerto Rican or foreign-born Hispanic women who preferred Spanish (odds ratio [OR]=2.76, 95% confidence interval [CI] 1.36, 5.63).

Conclusions. Our findings suggest that higher-acculturated Hispanic women living in the United States are more likely to smoke cigarettes during pregnancy than are less-acculturated Hispanic women. These results will inform interventions aimed at reducing cigarette smoking during pregnancy among US Hispanic women.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

 
Smoking during pregnancy is associated with numerous negative outcomes, including spontaneous abortion, stillbirth, perinatal death, low birthweight, preterm delivery, intrauterine growth retardation, and an increased risk of sudden infant death syndrome.^1–4 Smoking during pregnancy is commonplace in the United States, with an estimated 10.7% of pregnant women acknowledging smoking during pregnancy.⁵ Cigarette smoking is a particular concern for Hispanics, given that, in 2002, more than 21% of all births in the United States were to Hispanics and Hispanics had the highest fertility rate of any racial or ethnic group.^6,7 Hispanics are the largest minority group in the United States and are growing at the fastest rate of any racial or ethnic group.⁸

Regardless of pregnancy status, Hispanic women in the United States are less likely to smoke than are non-Hispanic Whites and Blacks. Age-adjusted data from the National Health Interview Survey of 2001 found that 10.9% of Hispanic women reported being current smokers compared with 22.7% of non-Hispanic Whites and 18.1% of non-Hispanic Blacks.⁵ In 2003, birth certificate data from the National Vital Statistics System found that 2.7% of Hispanic women reported smoking during pregnancy compared with 14.3% of non-Hispanic Whites and 8.3% of non-Hispanic Blacks.⁵ Smoking rates in the United States vary considerably by country of origin; for example, 7.9% of women of Puerto Rican origin report smoking during pregnancy compared with 2.0% of women of Mexican and 2.4% of women of Cuban origin.⁵

Hispanic women living in the United States are more likely to smoke than are Hispanic women living in their countries of origin. For example, only 0.9% of women in Puerto Rico report smoking during pregnancy compared with 7.9% of pregnant Puerto Rican women in the United States.^5,9 In Mexico, 4.5% of women report smoking compared with 9.6% of women of Mexican descent living in the United States.^5,10 These different rates may be explained by the more conservative attitudes toward cigarette smoking in traditional Hispanic cultures compared with US culture and the acculturation of women after arriving in the United States.^11,12 Acculturation is defined as the process of adopting the attitudes, beliefs, and behaviors of a new culture.¹³ The body of acculturation literature among non-pregnant women indicates that acculturation to the US culture is associated with the adoption of negative health behaviors that are more prevalent in this country.^14,15

Prior studies of pregnant Hispanic women suggest that increasing acculturation is associated with higher levels of smoking during pregnancy.^16–18 However, the majority of these studies were limited by small sample size and used only single measures of acculturation. Furthermore, these studies did not take into account parental birthplace. We were able to examine the association between cigarette smoking and parental and individual birthplace, language preference, and age at migration in a cohort of 1231 Hispanic prenatal-care patients. We hypothesized that pregnant Hispanic women in the United States with higher levels of acculturation would have higher rates of cigarette smoking compared with those with lower-acculturation levels.

	METHODS

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Sample
We utilized data from the Latina Gestational Diabetes Mellitus (Latina GDM) Study, a study with a prospective cohort of 1231 Hispanic prenatal-care patients that was conducted from July 2000 to July 2004 at Baystate Medical Center. Baystate is a large, tertiary care clinic in Springfield, Mass, that serves an ethnically and socioeconomically diverse population with approximately 5000 deliveries per year. The majority of Hispanic patients (90%) are of Puerto Rican descent. Women were eligible for the Latina GDM Study if they were seeking prenatal care at Baystate, self-identified as Hispanic, and were aged between 16 and 40 years. Women were eligible to participate in the study during only 1 pregnancy during the study period; for those with multiple pregnancies during the study period, we collected data from the first eligible pregnancy only.

Interviewers generated a list of potential participants by prescreening eligible patients according to demographic and medical characteristics provided on a daily roster of scheduled patients. Potential participants were asked if they would like to participate in the study and were further screened for eligibility. Reasons for exclusion included belonging to a racial/ethnic group other than Hispanic; having been diagnosed with type 2 diabetes, hypertension or heart disease, or chronic renal disease; having a multiple-gestation pregnancy; being aged younger than 16 or older than 40 years; being 24 or more weeks gestation at first interview; or prior participation in the study. Less than 1% of potential participants were excluded for existing medical history, 2% were excluded for nonsingleton pregnancy, and approximately 2% of eligible participants refused.

Procedures
Interviews were conducted in English or Spanish. To eliminate potential language barriers, the interview was conducted in the participant’s preferred language (Spanish or English). A first interview was conducted at the time of recruitment (< 24 weeks gestation), and a second interview was conducted at a subsequent prenatal care visit in mid-pregnancy (mean = 28 weeks gestation). The first interview assessed cigarette smoking and acculturation level; the second updated information on smoking in midpregnancy. Participants not located for their second interview in person were contacted by telephone. The second interview was completed by 782 (63.5%) of the 1231 enrolled participants. Of the enrolled participants who did not complete the second interview, 25.7% were not receiving their primary prenatal care at the clinic, 14.7% had a spontaneous abortion or preterm delivery, 12.2% had moved out of the area, and 47.4% could not be located at the clinic or contacted by telephone.

Measurements
Acculturation was modeled as the main independent variable in our analyses. Acculturation measures were derived from commonly used acculturation scales and included birthplace (not born in the United States or born in the continental United States); preferred language for reading, writing, and speaking (Spanish only, both Spanish and English [bilingual], or English only); age at migration for Puerto Rican or foreign-born participants; and parental birthplace for US-born participants. We scored each acculturation component so that a higher score reflected higher acculturation.

Participant and parental birthplace were scored as dichotomous variables, with those born outside the continental United States labeled as Puerto Rican or foreign born. Foreign born was given a value of 0, and US born a value of 1. Language preference was scored by assigning the value of 0 to each reported Spanish preference, 1 to each reported preference of both Spanish and English, and 2 to each reported preference of English in response to the speaking, reading, and writing questions. We created a 3-level language-preference index by classifying the language-preference index into Spanish-only (language-preference index = 0), English and Spanish (language-preference index = 1–5), and English-only (language-preference index = 6).

We divided age at time of migration into 4 categories to reflect periods of changing susceptibility to smoking: younger than 16 years, aged 16–25 years, older than 25 years, and for US-born women, aged 0.¹² The referent category was participants in the oldest age at migration group with a score of 0. Those who migrated between age 16 and 25 years were given a score of 1, those who migrated before age 16 years were given a score of 2, and US-born participants were given a score of 3, because their age at migration was essentially 0.

We examined the impact of parental birthplace on participant smoking. Parental and participant birthplace scores were summed to create a 4-level generation measure that compared foreign-born Hispanic women to US-born Hispanic women with 0, 1, or 2 US-born parents. We assumed that Puerto Rican or foreign-born participants had 2 Puerto Rican or foreign-born parents, but this information was not collected.

We created a 4-level acculturation measure by summing the language preference and birthplace scores. This measure ranged from Puerto Rican or foreign born, Spanish-only language preference to US born, English-only language preference.

Cigarette smoking was the outcome of interest in analyses. We assessed cigarette smoking as part of the first and second interview of the Latina GDM Study based upon questions from the Pregnancy Risk Assessment Monitoring System (PRAMS).¹⁹ Participants reported the number of cigarettes or packs of cigarettes smoked in an average day. Cigarette smoking was treated as a dichotomous variable ("any" versus "none"), with a positive response at either interview qualifying as cigarette use during pregnancy.

We collected information on potential and established covariates or risk factors for cigarette smoking during the interviews. Participants reported alcohol consumption during pregnancy as the number of alcoholic drinks consumed in an average week, and in the analysis, alcohol intake was treated as a dichotomous variable ("any" versus "none").

Perceived psychosocial stress, which was the stress experienced during pregnancy, was measured using Cohen’s perceived stress scale. Cohen’s perceived stress scale is designed to measure the degree to which situations in one’s life are considered stressful and a person’s sense of control over daily life demands. We summed ratings to provide scores ranging from 0 to 16, with higher scores indicating more perceived stress, and then split the scores into 3 categories.²⁰ Both the English and the Spanish version of the perceived stress scale have demonstrated high internal reliability (Cronbach’s.81) and test–retest correlation (r 0.73).^21,22

We used the Modified Life Events Inventory developed by Newton et al.²³ to collect the number of stressful life events experienced by participants during the pregnancy. The inventory provides a summed score of items relating to family illness and death, finances and job loss, relationships, physical injury, and legal matters.^23–25 The Spanish version of the questionnaire has been used by PRAMS for surveillance in states with sizable Hispanic populations.¹⁹

Stress and life events were analyzed continuously but reported as categorical variables for brevity. We collected information on other factors associated with cigarette smoking or acculturation including age, education, insurance, and income.^12,16,17,26

Statistical Analysis
We used SAS version 8 (SAS Institute Inc, Cary, NC) to perform statistical analyses. We computed means and percentages to describe characteristics of the study population. We performed the ² Cochran-Mantel-Haenszel test for categorical variables and analyses of variance (ANOVA; repeated-measures analysis of variance) test for continuous variables to test for differences between participants according to level of acculturation. We used ordinal logistic regression analyses to determine the association between acculturation and cigarette smoking during pregnancy.

Tests of trend were calculated by modeling ordinal participant characteristics as continuous variables (i.e., 1, 2, 3 ). We analyzed each acculturation measure separately because we expected significant correlation among the acculturation measures. We conducted multivariate logistic regression to examine the impact of changing acculturation level on the odds of smoking. We assessed confounding by adding each covariate separately to the unadjusted logistic model. Those covariates that changed the acculturation coefficients by more than 15% or which were important predictors of cigarette smoking in prior literature were retained in the final model.²⁷

	RESULTS

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The majority of participants were aged younger than 25 years at the time of study enrollment (70.8%) and did not have a high school education (55.6%; Table 1). The majority of participants (90.8%) reported being enrolled in Medicaid, and 57.2% had an annual household income of $15 000 or less. Most participants scored lower than or equal to 8 on the perceived stress scale (71.7%) and reported 2 or more stressful life events (53.2%). Approximately 21% of all participants reported smoking cigarettes at some time during their pregnancy, whereas only 1.4% reported drinking alcohol. The majority of participants who reported drinking alcohol also reported smoking cigarettes during pregnancy (11 of 16, 68.8%) and 4.6% of smokers reported drinking.

	DISCUSSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

Acculturation is generally associated with increases in socioeconomic status; yet, previous studies of Mexican Americans have suggested that smoking is most prevalent among highly acculturated populations with low socioeconomic status.^14,28 We adjusted for education, income, and health insurance as proxies of socioeconomic status and still found a higher odds of cigarette smoking in higher-acculturated participants, which suggests that acculturation has a separate influence on the odds of smoking. Although acculturation may not directly cause higher rates of cigarette smoking, it is likely a marker for a woman’s level of interaction with others who find such use acceptable and therefore is a marker of her assimilation to US culture.¹⁶

As with any study relying upon self-report, our assessment of cigarette use and other behaviors assessed are subject to misclassification However, the bulk of evidence suggests that women are truthful when reporting this information.^29,30 Self-reported smoking levels during pregnancy have been observed to be highly correlated with serum cotinine levels, exhaled carbon monoxide, and pregnancy outcomes such as low birth-weight.^30–32 Hispanics may be more likely than non-Hispanics to underreport both smoking and alcohol use, because these behaviors are not socially acceptable in traditional Hispanic cultures.^11,12 Furthermore, less-acculturated Hispanic women may un-derreport smoking more than more-acculturated women because of an increased social stigma, which would result in an overestimate of the observed associations. However, the rate of smoking reported by our study participants is higher than previously observed, even among low-acculturated women (17.9% of Puerto Rican or foreign-born women reported smoking), which suggests that women felt comfortable reporting their behaviors. Our study did not focus unduly on smoking information, and we attempted to minimize self-report concerns through repeated validation of responses and the use of bilingual interviewers who assured patients of confidentiality. In sum, any underreporting of smoking status was not likely to be substantial.

Our study excluded women with a history of chronic disease, a factor that may be related to smoking. However, because rates of these chronic diseases among women in the age range we studied are low, these exclusions are not likely to have resulted in significant underestimation of smoking prevalence in this population.

The country of origin of most of our participants may have contributed to the high rate of smoking reported. Previous studies have shown that Puerto Rican women living in the United States have higher rates of smoking during pregnancy (7.9%) than do other Hispanic groups such as Mexicans (2.0%) or Cubans (2.4%).⁵ Nearly three fourths (74.7%) of our sample was of Puerto Rican origin: 84.5% of Puerto Rican or foreign-born women were born in Puerto Rico, and 89.9% of US-born women had at least 1 parent born in Puerto Rico.

Measurements
There is currently no gold standard for the measurement of acculturation, and we did not utilize complete existing acculturation scales, because of competing study goals and concern regarding participant burden. However, we chose acculturation measures that are widely used, are frequent components of standardized acculturation scales, and are well validated.²⁶ Birthplace is a widely used measure of acculturation, which is often used for the validation of other acculturation measures and has been highly correlated with most standard scales of acculturation.²⁶ Generation is the most frequently used marker of acculturation.²⁶ Measures of language use and preference are among the most commonly used measures of acculturation and have been found to be significant predictors of acculturation, although the specific validity of language preference alone is unknown.²⁶ The use of language preference alone may not completely capture a participant’s ability to function in society and may have led to an underestimation of the ORs for the language preference and combined birth and language measures.

Prior studies of acculturation and smoking during pregnancy are sparse, and only 1 used a standardized acculturation scale.^16–18 Coonrod et al. used Cuellar’s Acculturation Scale in a study of 1024 Hispanic women who gave birth at Maricopa Medical Center in Phoenix, Ariz. The authors found that high-acculturated Hispanic women were more likely to smoke during pregnancy than were low-acculturated women (prevalence ratio 4.3; 95% CI = 2.3, 7.3).¹⁷ Similarly, we observed ORs of smoking ranging from 1.2 to 2.8 by acculturation level. A study by Vega et al. of 11 001 Hispanics who delivered at 202 California hospitals found an increased risk of smoking during pregnancy in US-born Hispanic women compared with Puerto Rican or foreign-born women (OR = 6.8; 95% CI not reported).¹⁸ Similarly, we observed an OR for smoking of 1.6 (95% CI = 1.0, 2.4) for Puerto Rican or foreign-born women compared with US-born women. A study by Acevedo of 331 low-income, pregnant Mexican American women in Denver found that unmarried, English-only speakers were more likely to smoke during pregnancy than were Spanish-only speakers (25% vs 3%).^16,18 Similarly, we found an OR for smoking of 2.7 (95% CI = 1.4, 5.2) for women who preferred only English compared with those who preferred only Spanish.

We did not collect information on parental smoking, a known predictor of individual smoking. However, parental smoking may be a pathway by which smoking increases in higher-acculturated women. Findings from our analysis according to parental birthplace did not show a statistically significant trend (P = .10), which suggests that parental birthplace is not highly predictive of a woman’s smoking odds during pregnancy. We expect some misclassification of parental birthplace for Puerto Rican or foreign-born participants because we did not collect this information and assumed all foreign-born women had foreign-born parents. Such misclassification would most likely have biased our results to the null hypothesis, because it would underestimate the acculturation level of some foreign-born women.

The combined birth and language-preference measure did not provide ORs that were considerably different from the language-preference measure alone. This may be attributable to considerable overlap between birthplace and language preference, because nearly all women born in the United States preferred English (84.9%).

We controlled for numerous established covariates in the relationship between acculturation and cigarette smoking. We found that education, insurance, stress levels, and income were positively associated with acculturation. Age was inversely associated with acculturation, which supports the hypothesis that younger immigrants acculturate faster than do older immigrants. Alcohol was shown to have an inverse, statistically nonsignificant association with acculturation, which suggests that alcohol may operate differently than does smoking with regard to acculturation. However, the number of women reporting alcohol use was too small to reach a meaningful conclusion.

Lack of information on marital status could have led to an overestimate of the association between acculturation and cigarette smoking, because marriage is associated with lower smoking rates and lower acculturation levels.^16,33 However, any potential overestimation is expected to be minimal, because we were able to control for other factors associated with marital status including age, education, and income. In addition, neither the association between marital status and cigarette smoking nor between marital status and acculturation were likely strong enough to have accounted for the entire association observed.^16,33

Because it is unlikely that nonsmokers in early pregnancy initiated smoking in midpregnancy and the second interview was used only to update smoking information, missing second interview data should have a minimal impact on prevalence rates of smoking in this sample. Indeed, only 3.7% of nonsmokers from the first interview subsequently reported smoking in the second interview (n = 32). Participants who missed the second interview did not differ statistically from those who completed the second interview in terms of smoking or any covariates included in the multivariate model (all P.13). Further, multivariate analysis findings were comparable when restricted to women who completed both interviews and to women who completed only 1 interview.

Because participants were recruited at prenatal care visits, we excluded women who did not receive prenatal care. Therefore, results from this study may not be generalizable to pregnant women not receiving prenatal care. However, our study population included a sizeable proportion of women who were at high risk for smoking on the basis of socioeconomic factors and ethnicity. In addition, statewide data for births by Hispanic women in Massachusetts from 1996 to 1999 indicate that 95.3% of Hispanic women in Massachusetts begin prenatal care by the end of the second trimester and have a total of 9 or more visits.³⁴

Conclusions
Increased rates of cigarette smoking among higher-acculturated women are of particular concern for pregnant women because of the negative impact cigarette use has on the fetus. In light of the growing population of Hispanic Americans, smoking in this population is a critical concern. Our observed prevalence rates of smoking are most generalizable to women of Puerto Rican origin; however, it may be reasonable to extrapolate from our findings an association between cigarette smoking and acculturation to women of various countries of origin when other health behaviors are controlled. Such an extension is supported by comparable findings in previous studies of predominantly Mexican American women and the higher-than-expected rate of smoking among the non–Puerto Rican Hispanic women in our sample (19.6%).^5,16–18 The results of this study suggest that US Hispanic women of predominantly Puerto Rican heritage with higher levels of acculturation are more likely to smoke during pregnancy than are less-acculturated women. The elucidation of the association between acculturation and negative health behaviors will inform interventions by identifying Hispanic women who are at higher odds of smoking during pregnancy.

	Acknowledgments

 
This work was supported by the American Diabetes Association Career Development (award 7-00-CD-02).

Human Participant Protection
Bilingual interviewers informed participants of study aims and procedures, and each participant read and signed a written consent document. This study was approved by the University of Massachusetts and University of Wisconsin’s institutional review boards.

	Footnotes

 
Peer Reviewed

Contributors
M. G. Detjen originated the idea and led the analyses and writing. L. Chasan-Taber and F. J. Nieto contributed significantly to the analyses and writing. L. Chasan-Taber was the principal investigator for the Latina Gestational Diabetes Mellitus Study. All authors helped to conceptualize ideas, interpret findings, and review drafts of the article.

Accepted for publication October 21, 2006.

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