EPITalk: Behind the Paper
This stimulating podcast series from the Annals of Epidemiology takes you behind the scenes of groundbreaking articles recently published in the journal. Join Editor-in-Chief, Patrick Sullivan, and journal authors for thought-provoking conversations on the latest findings and developments in epidemiologic and methodologic research.
EPITalk: Behind the Paper
Associations between Acculturation & Smoking Behaviors among Hispanics/Latinos
PhD candidate Adrienne Lee discusses her article, “Acculturation level and change in cigarette consumption behaviors among diverse Hispanics/Latinos: the Hispanic Community Health Study/Study of Latinos,” published in the August 2023 issue (Vol. 84) of Annals of Epidemiology. In this study, the researchers explore the influence of language acculturation on smoking behaviors in the U.S. Hispanic/Latino population and provide insights to inform culturally tailored smoking prevention and cessation strategies for the community.
Read the full article here:
https://www.sciencedirect.com/science/article/pii/S1047279723000893
Episode Credits:
- Executive Producer: Sabrina Debas
- Technical Producer: Paula Burrows
- Annals of Epidemiology is published by Elsevier.
Hello, you're listening to EPITalk: Behind the Paper, a monthly podcast from the Annals of Epidemiology. I'm Patrick Sullivan, Editor-in-Chief of the journal, and in this series we take you behind the scenes of some of the latest epidemiologic research featured in our journal. Today we're talking with Ms. Adrienne Lee about her article "A Culturation Level and Change in Cigarette Consumption Behaviors Among Diverse Hispanics/ Latinos: the Hispanic Community Health Study/ Study of Latinos. You can find the full article online in the August 2023 issue of the journal at www. annalsofepidemiology. org. So I want to introduce our guest today. Ms. Adrienne Lee is a PhD candidate in Epidemiology in the Joint Doctoral Program at the University of California, San Diego/S an Diego State University, and a recipient of the National Institute on Aging's Pre-to-Post-Doctoral Transition to Aging Research Award. Her research focuses on social and structural determinants of health and equitable aging in underserved minority populations. Ms. Lee, thank you so much for joining us today.
Adrienne Lee :Thank you, Patrick, for having me. I'm looking forward to our discussions.
Patrick Sullivan:Great. Well, let's jump in, because I really want to give people an idea both of what your research was about, but also the problem that you're trying to address. So can you start out just by giving me a little background on the problem that you were trying to address? Why is this issue important?
Adrienne Lee :Sure. So the Hispanic/ Latino population that's living in the United States is growing and is projected to increase by up to 50% in the next few decades, and as they live and age here in the United States, it's going to be important for us to better understand the key factors that influence modifiable health behaviors like smoking, which we're interested in in our current paper. Smoking cigarettes is well known to cause cancer, cardiovascular diseases and Alzheimer's diseases, among other comorbidities, and those outcomes also disproportionately impact the Hispanic Latino population, and so, despite certain heritage groups having a much higher burden of smoking than the general population, Hispanic/ Latinos tend to receive less cessation advice, and so if we aim to reduce the smoking behaviors in this population, with the ultimate goal of improving their health outcomes as they age in the United States, then we're going to need to inform smoking prevention and cessation strategies that are culturally tailored and effective for this community.
Patrick Sullivan:So I think that's a great explanation of why this is such an important issue. In the article, you really consider acculturation level as one of the potential social determinants for smoking behaviors. What prompted you to look at acculturation as one of your exposures?
Adrienne Lee :So our group was interested in studying acculturation level as a social determinant of health, largely in part because nearly every immigrant and child of immigrants that is in the United States is going to have some experience of acculturation, as two or more cultures collide, and so the process of acculturation is a multi- dimensional process in which you're retaining one's original culture as well as adopting some new aspects of your new culture and the interaction of those processes.
Adrienne Lee :And so there is evidence to suggest that acculturation level is associated with smoking behaviors in the Hispanic/ Latino population, largely noted in women, where higher levels of acculturation are actually associated with higher odds of smoking, whereas with men those tend to be null.
Adrienne Lee :Results are in the opposite direction. A lot of the research that has been done to date looking at the relationship between acculturation and smoking behaviors has been done cross-sectionally, looking at prevalence rates or quitting rates in the population and not necessarily individual changes to smoking behaviors. And so, as a goal of ours to ultimately change and reduce the smoking behaviors in this population, we wanted to focus on acculturation and the role that that plays, and I'll add that some of the existing theory as far as how acculturation may change behaviors and impact health in the Hispanic/ Latino population is through an interaction with socioeconomic status and as a proxy for social mobility for this population once they're in the United States, and so we really aimed to delve a little bit further into those relationships to hopefully better inform the strategies we use to modify these behaviors.
Patrick Sullivan:Right. Well, your answer just sort of sets up so perfectly where I want to end with this, which is you talked about the fact that there have been some cross-sectional kind of designs, but tell us about the study design that you use and the data sources that you use to answer these questions.
Adrienne Lee :Sure.
Adrienne Lee :So to address our research questions, we used data from the Hispanic Community Health Survey/ Study of Latinos and included participants who identified as current smokers at the baseline visit.
Adrienne Lee :We had two visits available for our study population in which self-reported individual level cigarette consumption data was available. Our primary exposure of interest was acculturation, language acculturation specifically, which was measured using a short acculturation scale for Hispanics, and we used primarily the language subscale because language explains most of the variability in acculturation constructs and it had the best psychometric properties for our study sample. We conducted analyses looking at change in consumption behaviors by comparing follow-up cigarette consumption behaviors to baseline in linear regressions, and we also measured quitting outcomes in logistic regressions using those individuals who were current smokers at baseline but who endorsed no longer smoking at their follow-up visit. We further stratified our analyses and conducted subgroup analyses by sex, educational attainment and migration status, and so we had about 2,000 individuals in our final study sample with two points of cigarette consumption data available, and we were able to really look at those individual level changes and the associations between acculturation and those smoking outcomes.
Patrick Sullivan:And about how far apart in time were the two measures?
Adrienne Lee :On average about seven years between the two visits six and a half to seven years.
Patrick Sullivan:It's quite a long interval to be able to get the callback and, like, have a usable response rate. So that's really interesting. So so, now you have us all queued up, what did you find? What was the sort of key finding around this relationship between acculturation and neither persistence or quitting of smoking?
Adrienne Lee :Sure. So subgroup analyses were quite informative, and what we found in our study is that among men who were daily smokers, higher levels of language acculturation were associated with increased cigarette consumption behaviors. So over the course of that seven-year period, on average men increased by one cigarette per day at those higher levels of acculturation. In our female sample we did not see what we had been expecting. We actually observed trends towards declines in cigarette consumption. Additionally, when we stratified our sample further by educational attainment, we got some really interesting results that weren't quite what we were expecting, and so we found that among daily smokers, those who had greater educational attainment and higher levels of language acculturation had a much lower odds of quitting and trended towards increased cigarette consumption behaviors. So our research does fill some important gaps in the literature and provides some points for additional research for us to really delve into this further.
Patrick Sullivan:Really interesting. What do you make of the difference between men and women? Sometimes we just say, like, that is what it is, and that raises more questions Like do you have any hypotheses based on literature or other data?
Adrienne Lee :So part of what could be explaining those sex differences that we observed may be the access and use of healthcare services, whereas individuals become more acculturated as far as their English language use and their ability to understand and intake prevention or cessation resources. That might be consistent. However, the sex differences of whether or not they're actually accessing those resources and uptaking the services that are being offered might be part of the explanation as to why we saw these differences in our findings, compared to those previous studies that looked at prevalence rates and sex differences in prevalence rates.
Patrick Sullivan:Yeah, you also had the difference between previous studies that have done prevalence based measures and now you're doing something that's longitudinal, and so I think that study design also depending on what the sort of patterns of use are, could also give you a different type of data. So that also might play in. How did the data source measure cigarette consumption behaviors?
Adrienne Lee :So for daily and non-daily smokers, well, everyone was asked whether or not they had a history of smoking and their lifetime and, if so, whether or not they were current users. And among those who were current users, they were asked whether they smoked daily or non-daily. And then, as far as consumption, they were asked specifically how many cigarettes per day on average they consume as daily smokers or as non-daily smokers.
Patrick Sullivan:On the days that they do smoke, the average number of cigarettes that are consumed per day so I'm going to just shout out to my Epi530 class because we've been talking about information bias and misclassification. So I just have to ask like do you have any concern about relying on self-reported data on cigarette consumption and sort of what's known about potential misclassification?
Adrienne Lee :Sure, and you know, self-reported measures kind of inherently introduced. These biases, and the ones that we're particularly concerned with in this study, would be social desirability bias and that recall bias, you know, recalling over the past year the average number of cigarettes that were smoked. I do believe that in the current study those biases would likely lead to under-reporting of consumed behaviors, where the true consumption may likely be higher than what was actually reported in the study. And so in that sense, while the bias is there, I think we would expect the results in the estimates to be still similar changes, if not larger changes in the true data versus what was reported in the study, and so in that sense we didn't do too much to try to evaluate that bias further. But that is what we would anticipate in this context.
Patrick Sullivan:Wonderful and uh- I am going to recommend this to my Epi5 30 students because that's exactly the kind of analysis we're working on developing in class, so thank you for that. So, compared to what others have found in terms of the association of acculturation and change in cigarette consumption behavior, particularly among Hispanic/ Latino individuals, how does what you found compare and why do you think it's the same or different, or stronger or weaker?
Adrienne Lee :Great question and so, as I mentioned, a lot of what we found was different from what has been published so far in studying these associations, and so, where we may have been expecting to find stronger associations in the women that were included in our study, what we found is that men in fact had these associations of higher acculturation level, leading to increased consumption behaviors, and so, as we kind of started to mention before, we're looking at individual changes and there's a lot of other factors that are going into changing behaviors, as opposed to how someone is behaving at any one given point in time.
Adrienne Lee :And within the scope of what we were able to do in this study, being one of the first studies to really look at this association, we had to keep it within the scope of our research questions.
Adrienne Lee :But some things to definitely consider, especially with our findings of sex differences, are, you know, those access to health care services or prevention services, and whether or not those are actually being uptaken by men or women and what those drivers are in those relationships. I think another thing that we found that was different from the literature and what we were expecting to see is that higher educational attainment with higher acculturation level was associated with lower odds of quitting, and I think that we expect that with greater acculturation level, you may have increased access to information and resources and people who are facilitating healthier behaviors, and that's not exactly what we see here. We're seeing that this higher education is either leading to persistent or increased smoking behaviors, and so really being able to further study why that was the case and what is driving that association I think is going to be an important next step in the research focused on the role of acculturation on smoking behaviors for our population.
Patrick Sullivan:Wonderful. Well, we're going to turn now from your research to understand a little bit about how it came about, and this is we call Behind the Paper, to try and understand a little bit more about the process and where everybody doing this kind of research were all people and so those sort of humanistic aspects of what we do. So I'm just going to open up a little discussion here. First, respect for producing this kind of really detailed analysis and getting it published during your PhD candidacy. It's amazing work. I wonder what was most challenging or maybe, if anything, was frustrating about conducting this particular research study. So what was engaging and enjoyable? What was more frustrating for you?
Adrienne Lee :Great question, and so I have to say that the most challenging part of this project was also the most engaging and enjoyable aspect of it, which is that this study cohort the study SOL: Study of Latinos has a very robust publication committee, and they assigned subject matter experts as co-authors to collaborate on these papers, and they also have an extensive review and approval process for publications using their data.
Adrienne Lee :And so the challenge there being, as a PhD student at UC San Diego and San Diego State University, the competing priorities that we have while managing a manuscript with so many co-authors and managing the expectations and the timelines of the committee within a reasonable time frame and ensuring that we're enlisting all of the feedback and expertise from those co-authors in developing this paper.
Adrienne Lee :I do think that ultimately, that was also a rewarding experience to get exposure, of managing and leading a project that has multiple stakeholders and co-authors involved in it, and ultimately it resulted in a much higher quality and well-informed publication, and so that engagement and collaboration was definitely enjoyable in the end, and I will say also that, when you keep in mind, the bigger picture of this publication committee and why they're doing their due diligence to ensure collaboration and to ensure high quality, results are being disseminated from this study ultimately comes back to the community and ensuring that the results that are being disseminated from this study are having a positive impact and are not doing harm to the individuals that we're aiming to serve, and that we're not unintentionally either perpetuating stereotypes or introducing stigma for this population that we're ultimately trying to serve. And so, while it was challenging at times, I think it was also very much the most engaging and enjoyable aspect of the process.
Patrick Sullivan:That's
Patrick Sullivan:I've never heard of that mechanism where there's this intentional involvement of people in the research, in the dissemination, in such a structured way. So it's just really exciting to hear about that. I mean, I wonder in that respect, like both the perspective of participants but also like academic partners, researchers why is it important to have that inclusion and representation of the community and Hispanic/L atino targeted research or practice and programming? How does that affect what comes out of the utility of it?
Adrienne Lee :Sure, and so I'll start by saying I may have buried the lead here.
Adrienne Lee :I am Hispanic/ Latina myself.
Adrienne Lee :I'm a first generation Dominican born in the US, and so, on a personal level, professionally, this was truly one of the first experiences that I've had where the majority of my collaborators were Hispanic/ Latino, and that doesn't just include my co-authors but the, you know, the people that were on the special interest working groups and in the publication committee.
Adrienne Lee :And so, from a personal level, I think just seeing that level of representation and an affirmation that there are spaces at the table not just for Hispanic/ Latinos but for Latinas in particular, and that our perspectives and our contributions are important and valued, I think is really important to see at that level for myself and just as I continue to aspire in my future career goals. But then, from a public health perspective, you know it's integral to health equity to involve the people from the community in all of the phases of research, from conceptualization through to dissemination, to ensure not only that the interests of the population are being considered and incorporated, but that their cultural norms and perceptions and those types of nuances are being incorporated into the research. That's being done with the ultimate goal of having effective interventions that make the intended impact for the most vulnerable people in our communities. So critically important to have that level of representation throughout the process and in research in general.
Patrick Sullivan:Thank you for that. I'm going to ask kind of a related question just about your own journey to public health and you're now in a place of health equity research, which I think is a new recognition and a critical recognition of a branch of these kinds of studies. How did your own background shape your professional goals and your interest in these areas?
Adrienne Lee :So I will say that my early on in my career trajectory I was interested in attending medical school, and so a lot of my experience after graduating from college was in a clinical setting, and I think my interest really pivoted from individual level care to more of this population level care when I was working as a clinical trials research coordinator at a cancer center, and in this role I was very closely working with and involved in the care and treatment of all of the study participants that we were enrolling in my trials.
Adrienne Lee :And so two things really started to stick out to me, which is that one the vast majority of the participants we enrolled in our trials were white, non Hispanic and socioeconomically from middle and upper classes, and the very few and far between black and Hispanic participants that we did enroll I found struggled with study adherence and often had not as favorable of health outcomes as some of the other participants.
Adrienne Lee :So this really started to bloom my curiosity and I asked them you know what are the reasons that we're not seeing you on? You know your scheduled study visit days and nine times out of 10. Very much socioeconomic factors, things like transportation or unable to get off of work, or your health insurance wasn't covering the services for the study, and so I really saw this spectrum of participants who were either able to fly into the city weekly for a 30 minute follow up visit. To the other end, you know, people who had to coordinate transportation through their church services and plan it a month in advance, and so these kinds of inequities just became very apparent to me and led me into more of a public health space and to wanting to have more of a population based impact for those individuals who were struggling the most in our society, to try and get them to have equitable outcomes when we're trying to treat or prevent any of the various health outcomes that we're interested in.
Patrick Sullivan:Yeah, you raise such important points and I think we see the same thing in Atlanta with research participants and it's a part of it is reflecting this sort of underlying inequities, but from a research perspective, it's also that exactly the same things which is the reason that some people don't come is because of transportation issues are needing to work and the sort of socio economically driven factors. So two things. That one is just the dignity and the respect of trying to make sure that each person gets what they need to be able to meaningfully participate. So for us that means some folks need Uber rides to get to the clinic visit and some folks don't, and so we provide that and we moved our research clinic to be like a block away from a Marta station, which is our urban train, in a subway system to try and minimize those barriers. So it's both about equity and respect for individuals, but it's also about the inclusion of diverse participants.
Patrick Sullivan:So there is also, from an epi point of view, a selection bias or retention bias that I think is really important In this case, like thinking a next layer down about how we, the equity lens of saying how do we make it equally easy for everyone to participate, which doesn't mean everybody needs to get the same thing, but it means that we're tailoring how we support people participating in research to meet their needs. It's both equitable and right, but it's also better for research and that we don't have some of those selection biases or retention biases, you know, if we take a one size fits all approach to how we support people in research, so it's interesting and analogous in a different population here. So last is someone who is in your PhD program. I want to do two things. One is you're going to be moving towards finishing and where do you want to head next for all of the folks who listen to, who may be have postdoc positions and junior faculty positions like where do you want to head and what's the next step for you when you're done?
Adrienne Lee :Thank you for that question, and so I will have a plug that the National Institute on Aging Award that I've received this year to finish my dissertation work as well as transition me into a postdoctoral position, is really one that is presenting me with a tremendous opportunity. I think the next phase in my professional development will be one to get additional training in additional social epidemiology, but also specifically in implementation science and really trying to kind of understand how, in with these evidence based practices, can we effectively translate these interventions into populations that we know are at great risk for certain aging outcomes, and so getting that type of exposure and experiences primarily what I am looking for in this next phase. I have a few institutions that are at the top of my list, but you can't reveal, all will be.
Adrienne Lee :Yeah, yeah, we'll go through the appropriate processes and ensuring that, you know, we end up in a place that has the resources to really continue to support my ultimate research goals.
Patrick Sullivan:One last question. You're in a doctoral program. You've survived, you've thrived, you've gotten this cool pre to post doctoral transition grant. What piece of advice would you have for students are coming into their doctoral program, based on what your experience has been?
Adrienne Lee :So my advice to incoming students would be to regularly reflect and update you know an individual development plan and to really be sure that they have goals in mind for the types of training or experiences that they want to gain during this program, and seeking out those opportunities, or creating those opportunities, so that you can ensure that you're getting what you want out of this program. As I mentioned, there's a lot of competing priorities when you're in a PhD program. It's not just the coursework or the qualifying exams you know, your paid research, but also the side projects that you participate in, and so managing your priorities and ensuring that you are getting what you want to get out of this opportunity with the time that you have.
Patrick Sullivan:But great advice and thank you for sharing that. So do you have any final thoughts that you'd like to share with our listeners?
Adrienne Lee :Just that- as public health professionals, we have, hopefully, a shared goal and interest to improve the health and well being of everyone that lives within our society, and not just to increase the lifespan but really increase the health span of individuals living within our communities, and so ensuring that we're taking this health equity approach and being able to identify those in our communities who need the most help to really be able to live happy and healthy long lives would be my public service announcement for the listeners today.
Patrick Sullivan:And what a great way to wrap up our episode. Thank you again so much for joining us today. It was really a pleasure to have you and we'll hope to see much more of your work at Annals of Epidemiology and the other places that you publish it in the future. Congratulations.
Adrienne Lee :Thank you so much for having me today.
Patrick Sullivan:I'm your host, Patrick Sullivan. Thanks for tuning in to this episode and see you next time on EPITalk, brought to you by Annals of Epidemiology, the official journal of the American College of Epidemiology. For a transcript of this podcast or to read the article featured in this episode and more from the journal, you can visit us online at www. annalsofepidemiology. org.
