Revisiting the Relationship Between Acculturation and Smoking Cessation Among Mexican Americans

Revisiting the Relationship Between Acculturation and Smoking Cessation Among Mexican Americans Abstract Background A well-established gender-differentiated association between acculturation and current smoking exists among Latino adults. There are far fewer studies on the potential influence of acculturation on smoking cessation, and extant findings are mixed. Purpose Using a multidimensional measure of acculturation, the current study examined the independent and interactive associations of gender and acculturation with smoking cessation among Mexican American smokers engaged in a quit attempt. Methods Using a latent variable modeling approach to repeated measures analysis, the independent and interaction effects of acculturation in two cultural directions (American and Mexican) were examined for their prospective associations with smoking abstinence. Interactions of acculturation domains with gender were also examined. Acculturation was assessed at baseline and abstinence status was assessed at 3 and 26 weeks post-quit. Results The interaction of American and Mexican cultural identity was significantly associated with smoking abstinence, such that greater American cultural identity was positively associated with abstinence only among those with high Mexican cultural identity. The interaction of English proficiency with gender was significant such that English proficiency was positively associated with abstinence among men but not women. Conclusions Findings in the cultural identity domain are consistent with a “benefits of biculturalism” perspective, and may be particularly relevant to the adoption of an American cultural orientation among persons with an already-strong heritage-culture orientation. Findings also replicate a gender-differentiated association between acculturation and cessation. Implications for treatment development and future research are discussed. Acculturation, Smoking cessation, Tobacco, Latinos The age- and sex-adjusted smoking prevalence rate among Latinos is lower than that of non-Latino Whites (9.9% vs. 17.4% [1]), and Latinos who smoke tend to do so at lower levels than non-Latino White smokers [2, 3]. Despite a less severe smoking pattern, notable tobacco-related disparities exist among Latinos in the USA. In particular, Latino smokers appear to be no more successful at quitting than are non-Latino White smokers [3–6]. Moreover, very few smoking cessation interventions have demonstrated efficacy among Latino smokers, and those that do exist have shown modest effects [7, 8]. To develop efficacious and culturally appropriate interventions, it is particularly important to know whether culturally relevant variables may uniquely or differentially influence cessation among Latino smokers attempting to quit [9]. Increased knowledge about culturally relevant determinants of smoking cessation may advance the development of new or adapted interventions that better target key mechanisms underlying cessation among Latino smokers. Acculturation has been a key factor hypothesized to influence smoking prevalence and cessation among Latinos in the USA. Therefore, the current study examined the relation between multiple domains of acculturation and smoking cessation among a cohort of Mexican American smokers who are attempting to quit. All participants received smoking cessation treatment (i.e., nicotine replacement therapy and counseling). Acculturation Acculturation is a multidimensional process of changes in cultural identity that includes selective adoption of the behaviors/practices, values, and self-identifications associated with the receiving culture (e.g., American), while selectively maintaining the behaviors/practices, values, and self-identifications associated with the heritage culture (e.g., Mexican or Latino [10]). The rate and extent of acculturative change as it relates to either Mexican or American cultural orientations or a particular aspect of identity (behaviors/practices, values, and self-identifications) can differ. For example, one can adopt an ethnic self-label such as Mexican or Latino and feel esteem regarding ethnic group membership (self-identification), while at the same time engaging in few behaviors or practices associated with Mexican culture (e.g., speaking Spanish or celebrating Mexican holidays; behaviors/practices). A multidimensional conceptualization of acculturation also allows for the experience of biculturalism, or simultaneous acculturation toward both the heritage and receiving cultures [10, 11]. There is ample research suggesting benefits of biculturalism in psychosocial adjustment. A bicultural identity is associated with lower anxiety and depression, and higher self-esteem, among others (see [11] for a meta-analysis of 83 studies). Given that the process of acculturation can occur relatively independently across multiple directions and domains of cultural identity, it is important to examine these multiple directions and domains for their independent and combined influences on behavior. Unfortunately, extant research in the area of smoking has typically taken a unidimensional approach to acculturation, with use of single-item sociodemographic variables (e.g., nativity, years of U.S. residency, English language usage) and unidimensional scales to operationalize acculturation. These measures appear to assess the behavioral domain (albeit weakly in some cases [12]) and misrepresent separate cultural orientations as two ends of a single continuum. As a result, these approaches to measuring acculturation have drawn considerable criticism for poor content and construct validity [10, 12–20]. Acculturation and Smoking Cessation among Latinos Studies have consistently found that unidimensional and proxy measures of acculturation interact with gender to predict smoking status among Latino adults. Specifically, greater acculturation toward American culture is associated with higher smoking prevalence rates among women, but not among men [21–29]. Much less work has examined the relationship between acculturation and smoking cessation among Latino smokers. The research that does exist has largely relied on unidimensional and proxy measures of acculturation, and has yielded inconsistent findings. Pérez-Stable and colleagues [30] found no relation between a five-item measure of English-language use and cessation. Using the same five-item measure, Leischow and colleagues [31] found that greater English-language usage was associated with higher odds of cessation. In contrast, Bock and colleagues [22] found lower cessation rates among Latino smokers who reported high English fluency compared with those who reported little to no English fluency on a single-item measure. Most recently, Wagener and colleagues [28] found no association of cessation with “more” versus “less” acculturation toward American culture. Because gender is a well-established moderator of the relation between acculturation and smoking prevalence, Castro and colleagues [32] examined the potential moderating role of gender on the relation between acculturation and cessation. They found a gender-differentiated relationship between smoking cessation and three proxies of acculturation toward American culture; more years of residency in the USA, a greater proportion of one’s life lived in the USA, and preference for English-language media were each associated with higher odds of cessation among men, but not among women. Explanatory Frameworks To date, explanations for the gender-differentiated relationships of acculturation with smoking prevalence or cessation among Latinos have relied mostly on social norms constructs [33]. Social norms constructs have been criticized for having weak and inconsistent relationships with behavior and behavioral intent [34]. Thus, there has been increased focus on identifying moderators of the influence of social norms on behavior [35, 36]. One candidate moderator that has emerged is group identity—that is, the strength of one’s identification with the group that holds the social norms in question [36, 37]. Speculation on mechanisms underlying the relationship between acculturation and smoking reflects this model of social norms. For the association between acculturation and smoking prevalence among Latinas, it has been argued that smoking prevalence increases with greater identification with American culture, because smoking is perceived as more common among women in the USA and social norms are relatively less disapproving toward women’s smoking in American culture compared with Latino cultures [21]. Alternatively—or in addition—smoking may be influenced by decreased identification with Latino culture, where smoking is perceived as less common among women and injunctive norms are relatively more disapproving of women’s smoking compared with American culture [21]. The lack of association between acculturation and smoking prevalence among men may be because descriptive and injunctive norms toward men’s smoking are similar across American and Latino cultures. In the single published study that found a gender-differentiated association of acculturation with smoking cessation, Castro and colleagues [32] similarly implicated social norms. They argued that if social norms associated with American culture are more encouraging toward cessation among men than are those associated with Latino culture, then cessation among Latino men may be influenced by greater identification with American culture and/or decreased identification with Latino culture. Thus, speculation on mechanisms underlying the relationship between behavioral proxies of acculturation and smoking behaviors among Latinos suggests that smoking reflects a behavioral acculturation that is driven by more intrinsic processes of acculturation in the domain of self-identification. However, due to use of unidirectional measures and proxies, the role of acculturation in the self-identification domain can only be regarded as speculation. In addition, it cannot be determined which (or whether both) directions of acculturation influence smoking or cessation. There are no known published studies examining the simultaneous or synergistic influence of multiple domains and directions of acculturation on smoking cessation. The Current Study The purpose of the current study was to examine American and Mexican cultural orientations in the behavioral/practices and self-identification acculturation domains for their independent and synergistic associations with abstinence among Mexican/Mexican American smokers engaged in a quit attempt. We used a multidimensional measure of acculturation that assesses language proficiency (a major aspect of behavioral acculturation) in English and Spanish, as well as endorsement of American and Mexican self-identification [38]. Consistent with previous research demonstrating the protective effects of biculturalism and a previous study that found a gender-differentiated relationship between sociodemographic proxies of acculturation and cessation among Latinos [32], we hypothesized the following: 1) The interaction of American and Mexican cultural orientations would be significantly associated with likelihood of cessation. In particular, persons with high scores on American and Mexican orientations (high Mexican and high American Cultural Identification scores, high English Proficiency and high Spanish Proficiency scores) would exhibit the highest likelihood of cessation. 2) Greater acculturation in the Mexican-oriented domains (Mexican Cultural Identification, and Spanish Proficiency) would be associated with lower likelihood of cessation, and greater acculturation in the American-oriented domains (American Cultural Identification and English Proficiency) would be associated with greater likelihood of cessation among men but not among women. 3) If Hypothesis 2 is supported, we would examine the social norms hypotheses outlined above. In line with social norms theory and speculation regarding the underlying mechanisms of the relationship between acculturation and smoking, we predicted that acculturation in the self-identification domains would account for the association between language proficiency and smoking cessation. Methods Participants The data used in the current study were collected as part of a longitudinal cohort study designed to examine neighborhood, individual, and acute intrapersonal and contextual determinants of smoking cessation among 199 Spanish-speaking Mexican American smokers receiving cessation counseling and attempting to quit. Inclusion criteria were (i) self-report of Mexican origin/heritage, (ii) preference to speak in Spanish, (iii) age 18–65 years old, (iv) smoke at least five cigarettes per day, (v) motivated to quit within the next 30 days, (vi) expired carbon monoxide (CO) level of ≥8 parts per million (ppm), and (vii) have a valid home address and phone number. Exclusion criteria included (i) contraindications for use of the nicotine patch, (ii) active substance use disorder, (iii) use of nicotine replacement products other than those supplied by the study, (iv) regular use of other tobacco products, (v) pregnancy or lactation, (vi) another household member enrolled in the study, or (vii) participated in a cessation program in the last 90 days. Procedures Eligibility screening of potential participants was conducted via telephone and final eligibility was determined at an in-person visit in which participants were provided with a detailed overview of the study, completed informed consent, and completed a baseline assessment. Participants were tracked from 1 week before their quit date (baseline) through 26 weeks post-quit. The study was conducted entirely in Spanish. All participants received smoking cessation treatment that included nicotine patch therapy, self-help materials, and up to six brief counseling sessions spanning the time from baseline assessment to 3 weeks post-quit. Participants were compensated for assessment visits. Study procedures were approved by the Institutional Review Board of the University of Texas MD Anderson Cancer Center. The current study used questionnaire data collected at baseline and abstinence status assessed at the 3- and 26-week post-quit follow-up sessions. Measures Acculturation Acculturation domains were assessed with the Multidimensional Acculturation Scale II (MAS-II [38]). The MAS-II is a 22-item self-report measure that comprises four subscales: English Proficiency, Spanish Proficiency, American Cultural Identification, and Mexican Cultural Identification. Language proficiency items assess ability and pleasure taken in use of the language. Mean scores range from 1 to 5.16 for English Proficiency and 1 to 5.2 for Spanish Proficiency. Cultural identification items assess cultural identification and pride, importance of cultural values, and pleasure taken in cultural practices. Mean scores range from 1 to 5. Higher mean scores on each MAS-II subscale are interpreted as greater acculturation on the respective factor. Reliability (coefficient ω [39]) for the MAS-II subscales in the current study was as follows: English proficiency = .90, Spanish Proficiency = .71, American Cultural Identification = .83, and Mexican Cultural Identification = .82. Demographics Sociodemographic data used in the current study included age, gender, education (high school education or less vs. more than a high school education), employment (employed [full-time or part-time] vs. not employed), annual household income, and nativity (U.S.-born vs. not U.S.-born). Income was measured with an ordinal scale (1–11) representing 11 income ranges (1 = $0–$2,400, 11 = $84,000 or more). Tobacco dependence Indicators of tobacco dependence used in the current study were a single item assessing the typical time lapse between waking and smoking one’s first cigarette of the day (TTFC; “within 5 min of waking” vs. “more than 5 min after waking) and a single item assessing typical number of cigarettes smoked per day (CPD). Smoking abstinence At both the 3- and 26-week follow-up assessment, smoking abstinence (0 = non-abstinent and 1 = abstinent) was defined as self-report of no smoking in the last 7 days and an expired CO level of <8 ppm [40]. Analytic Plan Data were examined for normality utilizing visual inspection of histograms and standardized skewness and kurtosis statistics with absolute values greater than 1.96 [41]. Variables were examined for collinearity as indicated by correlations greater than 0.90 or critical values of less than 0.10 for tolerance and greater than 10 for variance inflation factor (VIF [42]). Proportions of missing data were computed, and multiple imputation procedures were used to account for missing data (see Supplementary Material 1 for details on the multiple imputation procedures used in the current study). Parameter estimates reported here are pooled across 20 imputed datasets according to Rubin’s rules [43]. Analyses conducted with imputed data were compared with analyses conducted with full information maximum likelihood while allowing observations with missing data on the predictors to be excluded from the analyses (n = 131–138). All analyses were replicated. The current study used a latent variable modeling approach to repeated measures analysis wherein measures of smoking abstinence were modeled as latent intercept and slope growth factors [44]. Specifically, a conditional latent growth curve model was specified wherein the latent intercept and slope growth factors were each regressed on the covariates and predictors of interests. A varying intercept/constant slope growth factor model was specified by constraining the variance of the latent slope growth factor, and the covariance of the latent slope and intercept growth factors to zero. In addition, longitudinal threshold invariance was modeled by constraining thresholds at both time points to zero. Model coefficients are thus interpreted as the change in the log odds of experiencing the outcome associated with a one-unit increase in the predictor, holding time constant. Models were estimated in Mplus Version 8 using maximum likelihood estimation with robust standard errors. The outcome variable of interest was the latent intercept growth factor comprised by smoking abstinence at the 3- and 26-week follow-up time points. All analyses controlled for age, education, employment status, annual household income, nativity, TTFC, and CPD. Gender was additionally controlled for in analyses where it was not the moderator variable of interest. Planned analyses Analysis of Hypothesis 1 consisted of two models. The first was a “language proficiency” model, which included English Proficiency, Spanish Proficiency, and their interaction term. The second was a “cultural identification” model which included American Cultural Identification, Mexican Cultural Identification, and their interaction term. English Proficiency and American Cultural Identification were the focal predictors, and Spanish Proficiency and Mexican Cultural Identification were the moderators, in their respective interaction analyses. Analysis of Hypothesis 2 consisted of four models. These were four separate analyses, one for each acculturation subscale that included gender and the interaction term of the subscale with gender. Each acculturation scale was the focal predictor in its respective interaction analysis, and gender was the moderator. Results Preliminary Analyses Data diagnostics All but one continuous variable of interest in this study (age) exhibited significant skewness or kurtosis. Correlations, tolerance, and VIF were in the acceptable range for all variables. There was no missing data on gender, age, educational attainment, or TTFC. Proportions of missing data on the remaining predictor variables ranged from 0.5% (employment status) to 13.6% (income). Proportion of missing data on the outcome variables was 15.6% for Week 3 abstinence status and 43.2% for Week 26 abstinence status. Participant characteristics Estimated sample descriptive statistics and bivariate correlations among the variables are summarized in Table 1. The majority of the sample was male (63.3%), employed (68.1%), and non-U.S. born (86.5%). Few participants earned a high school diploma (22.1%). On average, participants were about 39 years old and the mean annual household income score was 5.3 (in the range of $24,000–$30,000). The mean Spanish Proficiency score of the sample was significantly higher than the mean English Proficiency score (4.47 vs. 2.87, p < .001), likely reflecting the study’s inclusion criteria of a preference for Spanish. Similarly, the mean Mexican Cultural Identification score was significantly higher than the mean American Cultural Identification score (3.98 vs. 3.59, p < .001). Hypothesis 1: The interaction of American and Mexican cultural orientations would be significantly associated with likelihood of cessation. Table 1 Estimated sample descriptives and variable correlations   1  2  3  4  5  6  7  8  9  10  11  12  13  14  Abstinence status                              1. Abstinent Week 3  0.47 (.04)                            2. Abstinent Week 26  .27  0.21 (0.03)                          Demographics                              3. Age  −.01  .14  38.7 (0.72)                        4. High school diploma/GED  −.03  −.07  .06  0.22 (0.03)                      5. Employed  .07  .05  −.20  .01  0.68 (0.03)                    6. Male  .23  .02  −.29  .004  .24  0.63 (0.04)                  7. Income  .13  −.07  −.19  .25  .14  .34  5.3 (0.19)                8. Not U.S.-born  −.04  .06  −.06  −.11  .10  .09  −0.20  0.87 (0.03)              Physical dependence                              9. ≤5 min to first cigarette of day  −.17  −.26  .03  −.06  −.07  .01  −.11  .02  0.32 (0.03)            10. Cigarettes per day  −.05  −.21  .10  −.07  −.05  .06  .00  −.11  .39  15.8 (0.68)          MAS-II subscales                              11. American Cultural Identification  .11  .15  .12  .19  −.03  .01  .17  −.13  −.18  −.02  3.6 (0.06)        12. Mexican Cultural Identification  −.09  −.04  −.05  .15  −.04  −.15  .03  −.02  −.05  −.07  .47  4.0 (0.05)      13. English Proficiency  .18  .01  .04  .23  −.03  .09  .27  −.35  −.06  .04  .49  .18  2.9 (0.08)    14. Spanish Proficiency  −.13  −.02  .02  .17  .02  −.14  .03  .13  −.10  −.10  .17  .44  .15  4.5 (0.04)  Missingness                              15. Missing Week 3 abstinence status  −.04  −.24  −.02  −.06  −.06  .10  .05  .01  .06  .19  .01  .00  .04  .03  16. Missing Week 26 abstinence status  −.08  −.01  −.11  −.07  .04  .08  .06  −.07  .16  .07  −.10  −.06  −.02  −.07    1  2  3  4  5  6  7  8  9  10  11  12  13  14  Abstinence status                              1. Abstinent Week 3  0.47 (.04)                            2. Abstinent Week 26  .27  0.21 (0.03)                          Demographics                              3. Age  −.01  .14  38.7 (0.72)                        4. High school diploma/GED  −.03  −.07  .06  0.22 (0.03)                      5. Employed  .07  .05  −.20  .01  0.68 (0.03)                    6. Male  .23  .02  −.29  .004  .24  0.63 (0.04)                  7. Income  .13  −.07  −.19  .25  .14  .34  5.3 (0.19)                8. Not U.S.-born  −.04  .06  −.06  −.11  .10  .09  −0.20  0.87 (0.03)              Physical dependence                              9. ≤5 min to first cigarette of day  −.17  −.26  .03  −.06  −.07  .01  −.11  .02  0.32 (0.03)            10. Cigarettes per day  −.05  −.21  .10  −.07  −.05  .06  .00  −.11  .39  15.8 (0.68)          MAS-II subscales                              11. American Cultural Identification  .11  .15  .12  .19  −.03  .01  .17  −.13  −.18  −.02  3.6 (0.06)        12. Mexican Cultural Identification  −.09  −.04  −.05  .15  −.04  −.15  .03  −.02  −.05  −.07  .47  4.0 (0.05)      13. English Proficiency  .18  .01  .04  .23  −.03  .09  .27  −.35  −.06  .04  .49  .18  2.9 (0.08)    14. Spanish Proficiency  −.13  −.02  .02  .17  .02  −.14  .03  .13  −.10  −.10  .17  .44  .15  4.5 (0.04)  Missingness                              15. Missing Week 3 abstinence status  −.04  −.24  −.02  −.06  −.06  .10  .05  .01  .06  .19  .01  .00  .04  .03  16. Missing Week 26 abstinence status  −.08  −.01  −.11  −.07  .04  .08  .06  −.07  .16  .07  −.10  −.06  −.02  −.07  Except for correlations with missingness, estimates are pooled over 20 imputed datasets. Estimated means/proportions and standard errors are listed in the diagonal. Correlations with missingness were computed with the original dataset. MAS-II = Multidimensional Acculturation Scale II. View Large Table 1 Estimated sample descriptives and variable correlations   1  2  3  4  5  6  7  8  9  10  11  12  13  14  Abstinence status                              1. Abstinent Week 3  0.47 (.04)                            2. Abstinent Week 26  .27  0.21 (0.03)                          Demographics                              3. Age  −.01  .14  38.7 (0.72)                        4. High school diploma/GED  −.03  −.07  .06  0.22 (0.03)                      5. Employed  .07  .05  −.20  .01  0.68 (0.03)                    6. Male  .23  .02  −.29  .004  .24  0.63 (0.04)                  7. Income  .13  −.07  −.19  .25  .14  .34  5.3 (0.19)                8. Not U.S.-born  −.04  .06  −.06  −.11  .10  .09  −0.20  0.87 (0.03)              Physical dependence                              9. ≤5 min to first cigarette of day  −.17  −.26  .03  −.06  −.07  .01  −.11  .02  0.32 (0.03)            10. Cigarettes per day  −.05  −.21  .10  −.07  −.05  .06  .00  −.11  .39  15.8 (0.68)          MAS-II subscales                              11. American Cultural Identification  .11  .15  .12  .19  −.03  .01  .17  −.13  −.18  −.02  3.6 (0.06)        12. Mexican Cultural Identification  −.09  −.04  −.05  .15  −.04  −.15  .03  −.02  −.05  −.07  .47  4.0 (0.05)      13. English Proficiency  .18  .01  .04  .23  −.03  .09  .27  −.35  −.06  .04  .49  .18  2.9 (0.08)    14. Spanish Proficiency  −.13  −.02  .02  .17  .02  −.14  .03  .13  −.10  −.10  .17  .44  .15  4.5 (0.04)  Missingness                              15. Missing Week 3 abstinence status  −.04  −.24  −.02  −.06  −.06  .10  .05  .01  .06  .19  .01  .00  .04  .03  16. Missing Week 26 abstinence status  −.08  −.01  −.11  −.07  .04  .08  .06  −.07  .16  .07  −.10  −.06  −.02  −.07    1  2  3  4  5  6  7  8  9  10  11  12  13  14  Abstinence status                              1. Abstinent Week 3  0.47 (.04)                            2. Abstinent Week 26  .27  0.21 (0.03)                          Demographics                              3. Age  −.01  .14  38.7 (0.72)                        4. High school diploma/GED  −.03  −.07  .06  0.22 (0.03)                      5. Employed  .07  .05  −.20  .01  0.68 (0.03)                    6. Male  .23  .02  −.29  .004  .24  0.63 (0.04)                  7. Income  .13  −.07  −.19  .25  .14  .34  5.3 (0.19)                8. Not U.S.-born  −.04  .06  −.06  −.11  .10  .09  −0.20  0.87 (0.03)              Physical dependence                              9. ≤5 min to first cigarette of day  −.17  −.26  .03  −.06  −.07  .01  −.11  .02  0.32 (0.03)            10. Cigarettes per day  −.05  −.21  .10  −.07  −.05  .06  .00  −.11  .39  15.8 (0.68)          MAS-II subscales                              11. American Cultural Identification  .11  .15  .12  .19  −.03  .01  .17  −.13  −.18  −.02  3.6 (0.06)        12. Mexican Cultural Identification  −.09  −.04  −.05  .15  −.04  −.15  .03  −.02  −.05  −.07  .47  4.0 (0.05)      13. English Proficiency  .18  .01  .04  .23  −.03  .09  .27  −.35  −.06  .04  .49  .18  2.9 (0.08)    14. Spanish Proficiency  −.13  −.02  .02  .17  .02  −.14  .03  .13  −.10  −.10  .17  .44  .15  4.5 (0.04)  Missingness                              15. Missing Week 3 abstinence status  −.04  −.24  −.02  −.06  −.06  .10  .05  .01  .06  .19  .01  .00  .04  .03  16. Missing Week 26 abstinence status  −.08  −.01  −.11  −.07  .04  .08  .06  −.07  .16  .07  −.10  −.06  −.02  −.07  Except for correlations with missingness, estimates are pooled over 20 imputed datasets. Estimated means/proportions and standard errors are listed in the diagonal. Correlations with missingness were computed with the original dataset. MAS-II = Multidimensional Acculturation Scale II. View Large Results for cultural identification The interaction of Mexican Cultural Identification and American Cultural Identification on abstinence was statistically significant (unstandardized estimate [b] = 0.97, standard error of the estimate [SE b] = 0.39, p = .01; see Table 2 for a summary of the full model). Follow-up analyses using the Johnson-Neyman procedure indicated that the region of significance (i.e., the range of Mexican Cultural Identification scores at which the association between American Cultural Identification and smoking abstinence is statistically significant) corresponds to Mexican Cultural Identification scores of approximately 4.25 (demarcated in Fig. 1A by the vertical gray dashed line) and higher. As depicted in Fig. 1A, at and above this value of Mexican Cultural Identification scores (encompassed by the grey shaded region), the conditional effect of American Cultural Identification is positive, indicating that higher American Cultural Identification scores are associated with greater likelihood of abstinence. Furthermore, the size of the conditional effect increases with increasing Mexican Cultural Identification scores. Figure 1B depicts the probabilities of abstinence predicted by American Cultural Identification at values below and within the region of significance. At Mexican Cultural Identification scores below the region of significance, the predicted probability of abstinence is moderate and fluctuates very little across American Cultural Identification scores. At Mexican Cultural Identification scores within the region of significance, predicted probability of abstinence increases rapidly with increasing American Cultural Identification scores. Table 2 Summary of significant interaction effects Predictor  Estimate (SE)  p-value  Age  0.02 (0.03)  .48  Male  1.49 (0.61)  .01  High school diploma/GED  −0.57 (0.61)  .35  Employed  0.09 (0.57)  .88  Income  0.07 (0.11)  .55  Not U.S.-born  −0.34 (0.72)  .64  ≤5 min to first cigarette of day  −1.15 (0.59)  .05  Cigarettes per day  −0.01 (0.03)  .61  American Cultural Identification  −3.23 (1.59)  .04  Mexican Cultural Identification  −3.91 (1.44)  .01  Mexican × American Cultural Identification  0.97 (0.39)  .01  Age  0.02 (0.03)  .46  Male  −1.37 (1.55)  .38  High school diploma/GED  −0.65 (0.63)  .31  Employed  0.09 (0.60)  .88  Income  0.04 (0.12)  .73  Not U.S.-born  0.02 (0.80)  .98  ≤5 min to first cigarette of day  −1.11 (0.60)  .07  Cigarettes per day  −0.02 (0.03)  .59  English Proficiency  −0.06 (0.39)  .87  Gender × English Proficiency  1.04 (0.51)  .04  Predictor  Estimate (SE)  p-value  Age  0.02 (0.03)  .48  Male  1.49 (0.61)  .01  High school diploma/GED  −0.57 (0.61)  .35  Employed  0.09 (0.57)  .88  Income  0.07 (0.11)  .55  Not U.S.-born  −0.34 (0.72)  .64  ≤5 min to first cigarette of day  −1.15 (0.59)  .05  Cigarettes per day  −0.01 (0.03)  .61  American Cultural Identification  −3.23 (1.59)  .04  Mexican Cultural Identification  −3.91 (1.44)  .01  Mexican × American Cultural Identification  0.97 (0.39)  .01  Age  0.02 (0.03)  .46  Male  −1.37 (1.55)  .38  High school diploma/GED  −0.65 (0.63)  .31  Employed  0.09 (0.60)  .88  Income  0.04 (0.12)  .73  Not U.S.-born  0.02 (0.80)  .98  ≤5 min to first cigarette of day  −1.11 (0.60)  .07  Cigarettes per day  −0.02 (0.03)  .59  English Proficiency  −0.06 (0.39)  .87  Gender × English Proficiency  1.04 (0.51)  .04  Bold indicates estimate that is statistically significant. View Large Table 2 Summary of significant interaction effects Predictor  Estimate (SE)  p-value  Age  0.02 (0.03)  .48  Male  1.49 (0.61)  .01  High school diploma/GED  −0.57 (0.61)  .35  Employed  0.09 (0.57)  .88  Income  0.07 (0.11)  .55  Not U.S.-born  −0.34 (0.72)  .64  ≤5 min to first cigarette of day  −1.15 (0.59)  .05  Cigarettes per day  −0.01 (0.03)  .61  American Cultural Identification  −3.23 (1.59)  .04  Mexican Cultural Identification  −3.91 (1.44)  .01  Mexican × American Cultural Identification  0.97 (0.39)  .01  Age  0.02 (0.03)  .46  Male  −1.37 (1.55)  .38  High school diploma/GED  −0.65 (0.63)  .31  Employed  0.09 (0.60)  .88  Income  0.04 (0.12)  .73  Not U.S.-born  0.02 (0.80)  .98  ≤5 min to first cigarette of day  −1.11 (0.60)  .07  Cigarettes per day  −0.02 (0.03)  .59  English Proficiency  −0.06 (0.39)  .87  Gender × English Proficiency  1.04 (0.51)  .04  Predictor  Estimate (SE)  p-value  Age  0.02 (0.03)  .48  Male  1.49 (0.61)  .01  High school diploma/GED  −0.57 (0.61)  .35  Employed  0.09 (0.57)  .88  Income  0.07 (0.11)  .55  Not U.S.-born  −0.34 (0.72)  .64  ≤5 min to first cigarette of day  −1.15 (0.59)  .05  Cigarettes per day  −0.01 (0.03)  .61  American Cultural Identification  −3.23 (1.59)  .04  Mexican Cultural Identification  −3.91 (1.44)  .01  Mexican × American Cultural Identification  0.97 (0.39)  .01  Age  0.02 (0.03)  .46  Male  −1.37 (1.55)  .38  High school diploma/GED  −0.65 (0.63)  .31  Employed  0.09 (0.60)  .88  Income  0.04 (0.12)  .73  Not U.S.-born  0.02 (0.80)  .98  ≤5 min to first cigarette of day  −1.11 (0.60)  .07  Cigarettes per day  −0.02 (0.03)  .59  English Proficiency  −0.06 (0.39)  .87  Gender × English Proficiency  1.04 (0.51)  .04  Bold indicates estimate that is statistically significant. View Large Fig. 1. View largeDownload slide Follow up of the interaction between American and Mexican Cultural Identity. (A) Johnson-Neyman plot of the conditional effect. Black solid line = conditional effect as a function of Mexican Cultural Identity; black dotted lines = upper and lower 95% confidence intervals; gray area = region of significance; gray dashed line = point of demarcation for region of significance. (B) predicted probabilities of abstinence at two scores of Mexican Cultural Identity. MCI = Mexican Cultural Identity score; ns = not significant. Fig. 1. View largeDownload slide Follow up of the interaction between American and Mexican Cultural Identity. (A) Johnson-Neyman plot of the conditional effect. Black solid line = conditional effect as a function of Mexican Cultural Identity; black dotted lines = upper and lower 95% confidence intervals; gray area = region of significance; gray dashed line = point of demarcation for region of significance. (B) predicted probabilities of abstinence at two scores of Mexican Cultural Identity. MCI = Mexican Cultural Identity score; ns = not significant. Results for Spanish Proficiency The interaction of English Proficiency and Spanish Proficiency on abstinence was not statistically significant (b = 0.42, SE b = 0.37, p = .25). Hypothesis 2: Greater acculturation in the Mexican-oriented domains would be associated with lower likelihood of cessation, and greater acculturation in the American-oriented domains would be associated with greater likelihood of cessation among men but not among women. Results for cultural identification Interaction tests of gender with each cultural identification scale were not significant (b = 0.63, SE b = 0.59, p = .29 for American Cultural Identification; b = −0.18, SE b = 0.69, p = .79 for Mexican Cultural Identification). Results for language proficiency The interaction of gender and English Proficiency was statistically significant (b = 1.04, SE b = 0.51, p = .04; see Table 2 for a summary of the full model), Follow-up analyses of the significant interaction effect indicated that English Proficiency was associated with likelihood of abstinence among men but not among women. Among men, a one-point increase in English Proficiency was associated with over a 2.5-fold increase in the odds of abstinence (men: adjusted odds ratio [AOR] = 2.66, 95% CI = 1.27–5.58; cf. women: AOR = 0.94, 95% CI = 0.44–2.0). Predicted probabilities of abstinence by English Proficiency scores for men and women are depicted in Fig. 2. The interaction of gender and Spanish Proficiency was not statistically significant (b = −1.82, SE b = 0.96, p = .06). Fig. 2. View largeDownload slide Predicted probabilities of abstinence by English Proficiency. ns = not significant. Fig. 2. View largeDownload slide Predicted probabilities of abstinence by English Proficiency. ns = not significant. Post Hoc Analyses Two post hoc analyses were conducted in light of the current findings. As the planned analyses involving Spanish Proficiency were not significant, we ran a model containing only the lower order terms to examine whether Spanish Proficiency had a unique association with abstinence. There was no significant relationship between Spanish proficiency and abstinence (b = −0.59, SE b = 0.40, p = .14). To examine Hypothesis 3, that accounting for cultural identification would attenuate the relationships between language proficiency and abstinence, we examined a model that included both the interaction term of gender and English Proficiency, and interaction term of American and Mexican Cultural Identification, as well as their lower order terms. Both interaction terms remained significantly associated with abstinence (Gender × English Proficiency, b = 1.18, SE b = 0.53, p = .02; American Cultural Identification × Mexican Cultural Identification, b = 1.10, SE b = 0.41, p = .008). Discussion To the best of our knowledge, the current study is the first to examine multiple domains and dimensions of acculturation for their independent and synergistic associations with smoking cessation among Latino adults engaged in a quit attempt. Language proficiency was assessed separately for English and Spanish, and cultural identification was assessed separately for American and Mexican cultural orientations. Among individuals with high Mexican self-identification, higher American self-identification was associated with greater likelihood of abstinence. Individuals with high Mexican self-identification and high American self-identification—indicative of biculturalism—had the highest likelihood of successful cessation. Individuals with strong Mexican self-identification but low American self-identification were most vulnerable to cessation failure. The current study also demonstrated a gender-differentiated association of English Proficiency with smoking abstinence. Consistent with previous research [32], higher English Proficiency was associated with increased likelihood of abstinence among men but not women. These observed associations were significant above and beyond sociodemographics and tobacco dependence, and persisted even when examining both significant interaction terms and their lower order terms in a single analysis. Cultural Identification and Smoking Cessation Study results regarding the self-identification domains of acculturation are consistent with current hypotheses and extant research demonstrating the benefits of a bicultural orientation. However, because American Cultural Identification was not associated with cessation among persons with low Mexican Cultural Identification, results might also suggest that efforts to understand how acculturation toward American culture influences smoking cessation may only be relevant to U.S. Latinos who also have very strong ties to their Latino cultural identity. This may include Latinos who are immigrants to the USA or U.S.-born Latinos who were reared and/or live in environments that strongly promote Latino cultural identity. Although the current study cannot directly speak to the process of cultural change, the findings bring forth the hypothesis that for persons with an already-strong Latino cultural self-identification, the factors that explain the relation between a bicultural self-identification and cessation have more to do with protective factors associated with the adoption of an American cultural self-identification than with protective factors associated with maintaining a strong Latino cultural identification. Research in acculturation psychology identifies some factors associated with a bicultural orientation that may account for the relation between a bicultural orientation and smoking cessation. For example, a bicultural orientation has been found to be positively associated with psychological well-being broadly defined [45, 46, 47], self-esteem, better sociocultural competence [45, 48, 49], and greater social support networks [47], and negatively associated with depressive symptoms [49–51]. Any of these psychosocial factors may directly or indirectly (e.g., through other known determinants of cessation, such as self-efficacy or motivation) affect one’s likelihood of successful cessation. It should be noted that it is not known whether biculturalism leads to these benefits or vice versa; therefore, it is also unknown whether biculturalism per se, could be causally linked to cessation. Importantly, reliance on the benefits of biculturalism as the sole explanation for these findings applies a cultural deficit model [52]. Furthermore, the practical benefits of biculturalism may be limited in their impact on the advancement of smoking cessation interventions as most of the purported mechanisms are already targets of existing interventions (e.g., negative effect, social support, self-efficacy), and specific cultural factors (e.g., cultural identification) may either not be amenable to intervention or raise issues regarding the ethics or desirability of change efforts. To avoid a cultural deficits model, it may be more useful to interpret results within a person-in-context framework. Thus, it may be less useful to ask “what is it about persons that might have influenced differential cessation outcomes?” and more useful to ask “what is it about the broader context, including the intervention itself, which might have influenced differential cessation outcomes across persons?” For example, the likelihood of cessation was less favorable among persons with high Mexican self-identification unless they also had high American self-identification. Previous research has demonstrated that higher levels of discrimination are associated with a lower likelihood of cessation among Mexican origin smokers [53]. Therefore, it may be that larger societal problems that disadvantage particular subgroups of Mexican origin smokers could account for the findings. Similarly, it is possible that the intervention may have been better suited to address certain needs or preferences of persons with high American self-identification compared with those of persons with a more “monocultural” Mexican self-identification. Thus, an important next step might be to identify those aspects of the intervention (e.g., its components, materials, delivery, setting, messages, targets), that did and did not resonate with one’s cultural identifications, and gather knowledge from the priority population on how to improve attention to culturally relevant factors within an intervention [54–57]. Such research would lay the groundwork for the development of more culturally responsive—and thus potentially more effective—smoking cessation interventions. Language Proficiency and Smoking Cessation Language proficiency falls within the behavioral domain of acculturation, and the sociodemographic variables used as proxies for acculturation in Castro et al. [32] are most highly associated with the behavioral domain [12] (this is also demonstrated in the bivariate associations in Table 1). Thus, the current findings regarding English proficiency replicate those of Castro et al. The current study expands upon these previous findings in that it separates the effects of English and Spanish language proficiencies. In contrast to current hypotheses, cultural identification did not account for the associations of language proficiency with abstinence. When discussing similar findings regarding relations between language proficiency and psychosocial adjustment among Asian American college students, Kang et al. [58] noted that language is a major mechanism through which cultural information is exchanged. That is, language use or proficiency (much like other common demographic proxies of acculturation; e.g., nativity, years residing in the USA, proportion of life spent in the USA) may serve as indicators of one’s level of exposure to or “immersion” in the societal culture with which the language is associated. Thus, greater English language proficiency may facilitate more exposure to societal influences on behavior. Importantly, this explanation differs from previous speculation on the relationship between acculturation and smoking behavior in that previous explanations have conceptualized the relation between proxies of behavioral acculturation and smoking behavior as spurious, likely accounted for by changes in cultural identity and values. Kang et al. imply that language usage exerts indirect effects on outcomes by way of increasing exposure to societal and cultural determinants of those outcomes. In the context of smoking cessation, there may be culturally relevant American societal factors that are of particular relevance to Latino smokers, and greater exposure to these societal factors may facilitate quitting among Latino men. As such, extant explanatory models that implicate social norms may still be important avenues of research to pursue. Whether or not social norms toward men’s smoking cessation differ cross-culturally remains to be empirically investigated. More broadly, findings regarding language proficiency suggest a continued need to identify social/societal contextual factors that may facilitate or impede cessation efforts among Latino smokers, and the need to understand the process that determines their particular relevance to Latino men. Limitations and Conclusion The current findings are novel and in need of corroboration, particularly in the context of study limitations. For example, the current study focused on language proficiency rather than behavioral acculturation more broadly. Also, some conceptualizations of biculturalism emphasize integration of cultural identities rather than simply high acculturation in both directions [45], and this approach to biculturalism could not be examined here. Given the importance of gender in studies on acculturation and smoking, a highly worthwhile set of additional analyses would have been to examine the three-way interaction of gender and measures of each direction of acculturation. Although these analyses (not shown) were null, their contribution to the current study was limited due to the small sample size and subsequent risk of Type II error. Although a focus on Mexican-origin smokers avoids the pitfalls of either treating Latinos as a homogenous population or of gathering data from multiple Latino subgroups in numbers too small for meaningful analyses within or between groups, this approach limits generalizability. The current study had numerous other eligibility criteria that may further limit generalizability (14 inclusion/exclusion criteria in total). Because the outcome of interests was measured at only two time points, the current study was limited to a random intercept/fixed slope growth factor model. Therefore, the current study was unable to examine predictors of individual trajectories of abstinence over time. Finally, as there are no accepted methods for pooling indices of model fit in the case of multiple imputation, the overall fit of the estimated models could not be evaluated. However, it is important to note that current analyses were not intended to find an optimal set of empirical predictors, but rather to test hypotheses about the interaction term in a given model, holding all other predictors constant. Nevertheless, the current study’s results reflect recent conceptualizations of the acculturation construct [10] as a set of multiple related, but distinct, factors with the potential for unique associations with a given behavior. As such, the current findings underscore the practical and theoretical importance of directly modeling the bidirectional and multidimensional nature of the acculturation construct. Supplementary Material Supplementary material is available at Annals of Behavioral Medicine online. Acknowledgements The data utilized in the current study were part of a larger project funded by the National Institute of Minority Health and Health Disparities (NIMHD; P60MD000503). Preparation of this manuscript was funded in part by grants from the National Cancer Institute (K01CA157689), NIMHD (R00MD010648, R21MD011431), and American Cancer Society (MRSG-15-018-01-CPPB). The contents of this manuscript are solely the responsibility of the authors and do not represent the official views of the funding agencies. Compliance with Ethical Standards Authors’ Statement of Conflict of Interest and Adherence to Ethical Standards None of the authors any conflicts of interest pertaining to this work. Authors’ Contributions All authors have made substantial contributions to the study and have approved of the final manuscript. Primary Data Neither all nor parts of this manuscript have been previously published or presented, and the manuscript is not currently submitted elsewhere for review. Ethical Approval All study procedures were approved by the Institutional Review Board of the University of Texas MD Anderson Cancer Center. 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This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Annals of Behavioral Medicine Oxford University Press

Revisiting the Relationship Between Acculturation and Smoking Cessation Among Mexican Americans

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1532-4796
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10.1093/abm/kay029
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Abstract

Abstract Background A well-established gender-differentiated association between acculturation and current smoking exists among Latino adults. There are far fewer studies on the potential influence of acculturation on smoking cessation, and extant findings are mixed. Purpose Using a multidimensional measure of acculturation, the current study examined the independent and interactive associations of gender and acculturation with smoking cessation among Mexican American smokers engaged in a quit attempt. Methods Using a latent variable modeling approach to repeated measures analysis, the independent and interaction effects of acculturation in two cultural directions (American and Mexican) were examined for their prospective associations with smoking abstinence. Interactions of acculturation domains with gender were also examined. Acculturation was assessed at baseline and abstinence status was assessed at 3 and 26 weeks post-quit. Results The interaction of American and Mexican cultural identity was significantly associated with smoking abstinence, such that greater American cultural identity was positively associated with abstinence only among those with high Mexican cultural identity. The interaction of English proficiency with gender was significant such that English proficiency was positively associated with abstinence among men but not women. Conclusions Findings in the cultural identity domain are consistent with a “benefits of biculturalism” perspective, and may be particularly relevant to the adoption of an American cultural orientation among persons with an already-strong heritage-culture orientation. Findings also replicate a gender-differentiated association between acculturation and cessation. Implications for treatment development and future research are discussed. Acculturation, Smoking cessation, Tobacco, Latinos The age- and sex-adjusted smoking prevalence rate among Latinos is lower than that of non-Latino Whites (9.9% vs. 17.4% [1]), and Latinos who smoke tend to do so at lower levels than non-Latino White smokers [2, 3]. Despite a less severe smoking pattern, notable tobacco-related disparities exist among Latinos in the USA. In particular, Latino smokers appear to be no more successful at quitting than are non-Latino White smokers [3–6]. Moreover, very few smoking cessation interventions have demonstrated efficacy among Latino smokers, and those that do exist have shown modest effects [7, 8]. To develop efficacious and culturally appropriate interventions, it is particularly important to know whether culturally relevant variables may uniquely or differentially influence cessation among Latino smokers attempting to quit [9]. Increased knowledge about culturally relevant determinants of smoking cessation may advance the development of new or adapted interventions that better target key mechanisms underlying cessation among Latino smokers. Acculturation has been a key factor hypothesized to influence smoking prevalence and cessation among Latinos in the USA. Therefore, the current study examined the relation between multiple domains of acculturation and smoking cessation among a cohort of Mexican American smokers who are attempting to quit. All participants received smoking cessation treatment (i.e., nicotine replacement therapy and counseling). Acculturation Acculturation is a multidimensional process of changes in cultural identity that includes selective adoption of the behaviors/practices, values, and self-identifications associated with the receiving culture (e.g., American), while selectively maintaining the behaviors/practices, values, and self-identifications associated with the heritage culture (e.g., Mexican or Latino [10]). The rate and extent of acculturative change as it relates to either Mexican or American cultural orientations or a particular aspect of identity (behaviors/practices, values, and self-identifications) can differ. For example, one can adopt an ethnic self-label such as Mexican or Latino and feel esteem regarding ethnic group membership (self-identification), while at the same time engaging in few behaviors or practices associated with Mexican culture (e.g., speaking Spanish or celebrating Mexican holidays; behaviors/practices). A multidimensional conceptualization of acculturation also allows for the experience of biculturalism, or simultaneous acculturation toward both the heritage and receiving cultures [10, 11]. There is ample research suggesting benefits of biculturalism in psychosocial adjustment. A bicultural identity is associated with lower anxiety and depression, and higher self-esteem, among others (see [11] for a meta-analysis of 83 studies). Given that the process of acculturation can occur relatively independently across multiple directions and domains of cultural identity, it is important to examine these multiple directions and domains for their independent and combined influences on behavior. Unfortunately, extant research in the area of smoking has typically taken a unidimensional approach to acculturation, with use of single-item sociodemographic variables (e.g., nativity, years of U.S. residency, English language usage) and unidimensional scales to operationalize acculturation. These measures appear to assess the behavioral domain (albeit weakly in some cases [12]) and misrepresent separate cultural orientations as two ends of a single continuum. As a result, these approaches to measuring acculturation have drawn considerable criticism for poor content and construct validity [10, 12–20]. Acculturation and Smoking Cessation among Latinos Studies have consistently found that unidimensional and proxy measures of acculturation interact with gender to predict smoking status among Latino adults. Specifically, greater acculturation toward American culture is associated with higher smoking prevalence rates among women, but not among men [21–29]. Much less work has examined the relationship between acculturation and smoking cessation among Latino smokers. The research that does exist has largely relied on unidimensional and proxy measures of acculturation, and has yielded inconsistent findings. Pérez-Stable and colleagues [30] found no relation between a five-item measure of English-language use and cessation. Using the same five-item measure, Leischow and colleagues [31] found that greater English-language usage was associated with higher odds of cessation. In contrast, Bock and colleagues [22] found lower cessation rates among Latino smokers who reported high English fluency compared with those who reported little to no English fluency on a single-item measure. Most recently, Wagener and colleagues [28] found no association of cessation with “more” versus “less” acculturation toward American culture. Because gender is a well-established moderator of the relation between acculturation and smoking prevalence, Castro and colleagues [32] examined the potential moderating role of gender on the relation between acculturation and cessation. They found a gender-differentiated relationship between smoking cessation and three proxies of acculturation toward American culture; more years of residency in the USA, a greater proportion of one’s life lived in the USA, and preference for English-language media were each associated with higher odds of cessation among men, but not among women. Explanatory Frameworks To date, explanations for the gender-differentiated relationships of acculturation with smoking prevalence or cessation among Latinos have relied mostly on social norms constructs [33]. Social norms constructs have been criticized for having weak and inconsistent relationships with behavior and behavioral intent [34]. Thus, there has been increased focus on identifying moderators of the influence of social norms on behavior [35, 36]. One candidate moderator that has emerged is group identity—that is, the strength of one’s identification with the group that holds the social norms in question [36, 37]. Speculation on mechanisms underlying the relationship between acculturation and smoking reflects this model of social norms. For the association between acculturation and smoking prevalence among Latinas, it has been argued that smoking prevalence increases with greater identification with American culture, because smoking is perceived as more common among women in the USA and social norms are relatively less disapproving toward women’s smoking in American culture compared with Latino cultures [21]. Alternatively—or in addition—smoking may be influenced by decreased identification with Latino culture, where smoking is perceived as less common among women and injunctive norms are relatively more disapproving of women’s smoking compared with American culture [21]. The lack of association between acculturation and smoking prevalence among men may be because descriptive and injunctive norms toward men’s smoking are similar across American and Latino cultures. In the single published study that found a gender-differentiated association of acculturation with smoking cessation, Castro and colleagues [32] similarly implicated social norms. They argued that if social norms associated with American culture are more encouraging toward cessation among men than are those associated with Latino culture, then cessation among Latino men may be influenced by greater identification with American culture and/or decreased identification with Latino culture. Thus, speculation on mechanisms underlying the relationship between behavioral proxies of acculturation and smoking behaviors among Latinos suggests that smoking reflects a behavioral acculturation that is driven by more intrinsic processes of acculturation in the domain of self-identification. However, due to use of unidirectional measures and proxies, the role of acculturation in the self-identification domain can only be regarded as speculation. In addition, it cannot be determined which (or whether both) directions of acculturation influence smoking or cessation. There are no known published studies examining the simultaneous or synergistic influence of multiple domains and directions of acculturation on smoking cessation. The Current Study The purpose of the current study was to examine American and Mexican cultural orientations in the behavioral/practices and self-identification acculturation domains for their independent and synergistic associations with abstinence among Mexican/Mexican American smokers engaged in a quit attempt. We used a multidimensional measure of acculturation that assesses language proficiency (a major aspect of behavioral acculturation) in English and Spanish, as well as endorsement of American and Mexican self-identification [38]. Consistent with previous research demonstrating the protective effects of biculturalism and a previous study that found a gender-differentiated relationship between sociodemographic proxies of acculturation and cessation among Latinos [32], we hypothesized the following: 1) The interaction of American and Mexican cultural orientations would be significantly associated with likelihood of cessation. In particular, persons with high scores on American and Mexican orientations (high Mexican and high American Cultural Identification scores, high English Proficiency and high Spanish Proficiency scores) would exhibit the highest likelihood of cessation. 2) Greater acculturation in the Mexican-oriented domains (Mexican Cultural Identification, and Spanish Proficiency) would be associated with lower likelihood of cessation, and greater acculturation in the American-oriented domains (American Cultural Identification and English Proficiency) would be associated with greater likelihood of cessation among men but not among women. 3) If Hypothesis 2 is supported, we would examine the social norms hypotheses outlined above. In line with social norms theory and speculation regarding the underlying mechanisms of the relationship between acculturation and smoking, we predicted that acculturation in the self-identification domains would account for the association between language proficiency and smoking cessation. Methods Participants The data used in the current study were collected as part of a longitudinal cohort study designed to examine neighborhood, individual, and acute intrapersonal and contextual determinants of smoking cessation among 199 Spanish-speaking Mexican American smokers receiving cessation counseling and attempting to quit. Inclusion criteria were (i) self-report of Mexican origin/heritage, (ii) preference to speak in Spanish, (iii) age 18–65 years old, (iv) smoke at least five cigarettes per day, (v) motivated to quit within the next 30 days, (vi) expired carbon monoxide (CO) level of ≥8 parts per million (ppm), and (vii) have a valid home address and phone number. Exclusion criteria included (i) contraindications for use of the nicotine patch, (ii) active substance use disorder, (iii) use of nicotine replacement products other than those supplied by the study, (iv) regular use of other tobacco products, (v) pregnancy or lactation, (vi) another household member enrolled in the study, or (vii) participated in a cessation program in the last 90 days. Procedures Eligibility screening of potential participants was conducted via telephone and final eligibility was determined at an in-person visit in which participants were provided with a detailed overview of the study, completed informed consent, and completed a baseline assessment. Participants were tracked from 1 week before their quit date (baseline) through 26 weeks post-quit. The study was conducted entirely in Spanish. All participants received smoking cessation treatment that included nicotine patch therapy, self-help materials, and up to six brief counseling sessions spanning the time from baseline assessment to 3 weeks post-quit. Participants were compensated for assessment visits. Study procedures were approved by the Institutional Review Board of the University of Texas MD Anderson Cancer Center. The current study used questionnaire data collected at baseline and abstinence status assessed at the 3- and 26-week post-quit follow-up sessions. Measures Acculturation Acculturation domains were assessed with the Multidimensional Acculturation Scale II (MAS-II [38]). The MAS-II is a 22-item self-report measure that comprises four subscales: English Proficiency, Spanish Proficiency, American Cultural Identification, and Mexican Cultural Identification. Language proficiency items assess ability and pleasure taken in use of the language. Mean scores range from 1 to 5.16 for English Proficiency and 1 to 5.2 for Spanish Proficiency. Cultural identification items assess cultural identification and pride, importance of cultural values, and pleasure taken in cultural practices. Mean scores range from 1 to 5. Higher mean scores on each MAS-II subscale are interpreted as greater acculturation on the respective factor. Reliability (coefficient ω [39]) for the MAS-II subscales in the current study was as follows: English proficiency = .90, Spanish Proficiency = .71, American Cultural Identification = .83, and Mexican Cultural Identification = .82. Demographics Sociodemographic data used in the current study included age, gender, education (high school education or less vs. more than a high school education), employment (employed [full-time or part-time] vs. not employed), annual household income, and nativity (U.S.-born vs. not U.S.-born). Income was measured with an ordinal scale (1–11) representing 11 income ranges (1 = $0–$2,400, 11 = $84,000 or more). Tobacco dependence Indicators of tobacco dependence used in the current study were a single item assessing the typical time lapse between waking and smoking one’s first cigarette of the day (TTFC; “within 5 min of waking” vs. “more than 5 min after waking) and a single item assessing typical number of cigarettes smoked per day (CPD). Smoking abstinence At both the 3- and 26-week follow-up assessment, smoking abstinence (0 = non-abstinent and 1 = abstinent) was defined as self-report of no smoking in the last 7 days and an expired CO level of <8 ppm [40]. Analytic Plan Data were examined for normality utilizing visual inspection of histograms and standardized skewness and kurtosis statistics with absolute values greater than 1.96 [41]. Variables were examined for collinearity as indicated by correlations greater than 0.90 or critical values of less than 0.10 for tolerance and greater than 10 for variance inflation factor (VIF [42]). Proportions of missing data were computed, and multiple imputation procedures were used to account for missing data (see Supplementary Material 1 for details on the multiple imputation procedures used in the current study). Parameter estimates reported here are pooled across 20 imputed datasets according to Rubin’s rules [43]. Analyses conducted with imputed data were compared with analyses conducted with full information maximum likelihood while allowing observations with missing data on the predictors to be excluded from the analyses (n = 131–138). All analyses were replicated. The current study used a latent variable modeling approach to repeated measures analysis wherein measures of smoking abstinence were modeled as latent intercept and slope growth factors [44]. Specifically, a conditional latent growth curve model was specified wherein the latent intercept and slope growth factors were each regressed on the covariates and predictors of interests. A varying intercept/constant slope growth factor model was specified by constraining the variance of the latent slope growth factor, and the covariance of the latent slope and intercept growth factors to zero. In addition, longitudinal threshold invariance was modeled by constraining thresholds at both time points to zero. Model coefficients are thus interpreted as the change in the log odds of experiencing the outcome associated with a one-unit increase in the predictor, holding time constant. Models were estimated in Mplus Version 8 using maximum likelihood estimation with robust standard errors. The outcome variable of interest was the latent intercept growth factor comprised by smoking abstinence at the 3- and 26-week follow-up time points. All analyses controlled for age, education, employment status, annual household income, nativity, TTFC, and CPD. Gender was additionally controlled for in analyses where it was not the moderator variable of interest. Planned analyses Analysis of Hypothesis 1 consisted of two models. The first was a “language proficiency” model, which included English Proficiency, Spanish Proficiency, and their interaction term. The second was a “cultural identification” model which included American Cultural Identification, Mexican Cultural Identification, and their interaction term. English Proficiency and American Cultural Identification were the focal predictors, and Spanish Proficiency and Mexican Cultural Identification were the moderators, in their respective interaction analyses. Analysis of Hypothesis 2 consisted of four models. These were four separate analyses, one for each acculturation subscale that included gender and the interaction term of the subscale with gender. Each acculturation scale was the focal predictor in its respective interaction analysis, and gender was the moderator. Results Preliminary Analyses Data diagnostics All but one continuous variable of interest in this study (age) exhibited significant skewness or kurtosis. Correlations, tolerance, and VIF were in the acceptable range for all variables. There was no missing data on gender, age, educational attainment, or TTFC. Proportions of missing data on the remaining predictor variables ranged from 0.5% (employment status) to 13.6% (income). Proportion of missing data on the outcome variables was 15.6% for Week 3 abstinence status and 43.2% for Week 26 abstinence status. Participant characteristics Estimated sample descriptive statistics and bivariate correlations among the variables are summarized in Table 1. The majority of the sample was male (63.3%), employed (68.1%), and non-U.S. born (86.5%). Few participants earned a high school diploma (22.1%). On average, participants were about 39 years old and the mean annual household income score was 5.3 (in the range of $24,000–$30,000). The mean Spanish Proficiency score of the sample was significantly higher than the mean English Proficiency score (4.47 vs. 2.87, p < .001), likely reflecting the study’s inclusion criteria of a preference for Spanish. Similarly, the mean Mexican Cultural Identification score was significantly higher than the mean American Cultural Identification score (3.98 vs. 3.59, p < .001). Hypothesis 1: The interaction of American and Mexican cultural orientations would be significantly associated with likelihood of cessation. Table 1 Estimated sample descriptives and variable correlations   1  2  3  4  5  6  7  8  9  10  11  12  13  14  Abstinence status                              1. Abstinent Week 3  0.47 (.04)                            2. Abstinent Week 26  .27  0.21 (0.03)                          Demographics                              3. Age  −.01  .14  38.7 (0.72)                        4. High school diploma/GED  −.03  −.07  .06  0.22 (0.03)                      5. Employed  .07  .05  −.20  .01  0.68 (0.03)                    6. Male  .23  .02  −.29  .004  .24  0.63 (0.04)                  7. Income  .13  −.07  −.19  .25  .14  .34  5.3 (0.19)                8. Not U.S.-born  −.04  .06  −.06  −.11  .10  .09  −0.20  0.87 (0.03)              Physical dependence                              9. ≤5 min to first cigarette of day  −.17  −.26  .03  −.06  −.07  .01  −.11  .02  0.32 (0.03)            10. Cigarettes per day  −.05  −.21  .10  −.07  −.05  .06  .00  −.11  .39  15.8 (0.68)          MAS-II subscales                              11. American Cultural Identification  .11  .15  .12  .19  −.03  .01  .17  −.13  −.18  −.02  3.6 (0.06)        12. Mexican Cultural Identification  −.09  −.04  −.05  .15  −.04  −.15  .03  −.02  −.05  −.07  .47  4.0 (0.05)      13. English Proficiency  .18  .01  .04  .23  −.03  .09  .27  −.35  −.06  .04  .49  .18  2.9 (0.08)    14. Spanish Proficiency  −.13  −.02  .02  .17  .02  −.14  .03  .13  −.10  −.10  .17  .44  .15  4.5 (0.04)  Missingness                              15. Missing Week 3 abstinence status  −.04  −.24  −.02  −.06  −.06  .10  .05  .01  .06  .19  .01  .00  .04  .03  16. Missing Week 26 abstinence status  −.08  −.01  −.11  −.07  .04  .08  .06  −.07  .16  .07  −.10  −.06  −.02  −.07    1  2  3  4  5  6  7  8  9  10  11  12  13  14  Abstinence status                              1. Abstinent Week 3  0.47 (.04)                            2. Abstinent Week 26  .27  0.21 (0.03)                          Demographics                              3. Age  −.01  .14  38.7 (0.72)                        4. High school diploma/GED  −.03  −.07  .06  0.22 (0.03)                      5. Employed  .07  .05  −.20  .01  0.68 (0.03)                    6. Male  .23  .02  −.29  .004  .24  0.63 (0.04)                  7. Income  .13  −.07  −.19  .25  .14  .34  5.3 (0.19)                8. Not U.S.-born  −.04  .06  −.06  −.11  .10  .09  −0.20  0.87 (0.03)              Physical dependence                              9. ≤5 min to first cigarette of day  −.17  −.26  .03  −.06  −.07  .01  −.11  .02  0.32 (0.03)            10. Cigarettes per day  −.05  −.21  .10  −.07  −.05  .06  .00  −.11  .39  15.8 (0.68)          MAS-II subscales                              11. American Cultural Identification  .11  .15  .12  .19  −.03  .01  .17  −.13  −.18  −.02  3.6 (0.06)        12. Mexican Cultural Identification  −.09  −.04  −.05  .15  −.04  −.15  .03  −.02  −.05  −.07  .47  4.0 (0.05)      13. English Proficiency  .18  .01  .04  .23  −.03  .09  .27  −.35  −.06  .04  .49  .18  2.9 (0.08)    14. Spanish Proficiency  −.13  −.02  .02  .17  .02  −.14  .03  .13  −.10  −.10  .17  .44  .15  4.5 (0.04)  Missingness                              15. Missing Week 3 abstinence status  −.04  −.24  −.02  −.06  −.06  .10  .05  .01  .06  .19  .01  .00  .04  .03  16. Missing Week 26 abstinence status  −.08  −.01  −.11  −.07  .04  .08  .06  −.07  .16  .07  −.10  −.06  −.02  −.07  Except for correlations with missingness, estimates are pooled over 20 imputed datasets. Estimated means/proportions and standard errors are listed in the diagonal. Correlations with missingness were computed with the original dataset. MAS-II = Multidimensional Acculturation Scale II. View Large Table 1 Estimated sample descriptives and variable correlations   1  2  3  4  5  6  7  8  9  10  11  12  13  14  Abstinence status                              1. Abstinent Week 3  0.47 (.04)                            2. Abstinent Week 26  .27  0.21 (0.03)                          Demographics                              3. Age  −.01  .14  38.7 (0.72)                        4. High school diploma/GED  −.03  −.07  .06  0.22 (0.03)                      5. Employed  .07  .05  −.20  .01  0.68 (0.03)                    6. Male  .23  .02  −.29  .004  .24  0.63 (0.04)                  7. Income  .13  −.07  −.19  .25  .14  .34  5.3 (0.19)                8. Not U.S.-born  −.04  .06  −.06  −.11  .10  .09  −0.20  0.87 (0.03)              Physical dependence                              9. ≤5 min to first cigarette of day  −.17  −.26  .03  −.06  −.07  .01  −.11  .02  0.32 (0.03)            10. Cigarettes per day  −.05  −.21  .10  −.07  −.05  .06  .00  −.11  .39  15.8 (0.68)          MAS-II subscales                              11. American Cultural Identification  .11  .15  .12  .19  −.03  .01  .17  −.13  −.18  −.02  3.6 (0.06)        12. Mexican Cultural Identification  −.09  −.04  −.05  .15  −.04  −.15  .03  −.02  −.05  −.07  .47  4.0 (0.05)      13. English Proficiency  .18  .01  .04  .23  −.03  .09  .27  −.35  −.06  .04  .49  .18  2.9 (0.08)    14. Spanish Proficiency  −.13  −.02  .02  .17  .02  −.14  .03  .13  −.10  −.10  .17  .44  .15  4.5 (0.04)  Missingness                              15. Missing Week 3 abstinence status  −.04  −.24  −.02  −.06  −.06  .10  .05  .01  .06  .19  .01  .00  .04  .03  16. Missing Week 26 abstinence status  −.08  −.01  −.11  −.07  .04  .08  .06  −.07  .16  .07  −.10  −.06  −.02  −.07    1  2  3  4  5  6  7  8  9  10  11  12  13  14  Abstinence status                              1. Abstinent Week 3  0.47 (.04)                            2. Abstinent Week 26  .27  0.21 (0.03)                          Demographics                              3. Age  −.01  .14  38.7 (0.72)                        4. High school diploma/GED  −.03  −.07  .06  0.22 (0.03)                      5. Employed  .07  .05  −.20  .01  0.68 (0.03)                    6. Male  .23  .02  −.29  .004  .24  0.63 (0.04)                  7. Income  .13  −.07  −.19  .25  .14  .34  5.3 (0.19)                8. Not U.S.-born  −.04  .06  −.06  −.11  .10  .09  −0.20  0.87 (0.03)              Physical dependence                              9. ≤5 min to first cigarette of day  −.17  −.26  .03  −.06  −.07  .01  −.11  .02  0.32 (0.03)            10. Cigarettes per day  −.05  −.21  .10  −.07  −.05  .06  .00  −.11  .39  15.8 (0.68)          MAS-II subscales                              11. American Cultural Identification  .11  .15  .12  .19  −.03  .01  .17  −.13  −.18  −.02  3.6 (0.06)        12. Mexican Cultural Identification  −.09  −.04  −.05  .15  −.04  −.15  .03  −.02  −.05  −.07  .47  4.0 (0.05)      13. English Proficiency  .18  .01  .04  .23  −.03  .09  .27  −.35  −.06  .04  .49  .18  2.9 (0.08)    14. Spanish Proficiency  −.13  −.02  .02  .17  .02  −.14  .03  .13  −.10  −.10  .17  .44  .15  4.5 (0.04)  Missingness                              15. Missing Week 3 abstinence status  −.04  −.24  −.02  −.06  −.06  .10  .05  .01  .06  .19  .01  .00  .04  .03  16. Missing Week 26 abstinence status  −.08  −.01  −.11  −.07  .04  .08  .06  −.07  .16  .07  −.10  −.06  −.02  −.07  Except for correlations with missingness, estimates are pooled over 20 imputed datasets. Estimated means/proportions and standard errors are listed in the diagonal. Correlations with missingness were computed with the original dataset. MAS-II = Multidimensional Acculturation Scale II. View Large Results for cultural identification The interaction of Mexican Cultural Identification and American Cultural Identification on abstinence was statistically significant (unstandardized estimate [b] = 0.97, standard error of the estimate [SE b] = 0.39, p = .01; see Table 2 for a summary of the full model). Follow-up analyses using the Johnson-Neyman procedure indicated that the region of significance (i.e., the range of Mexican Cultural Identification scores at which the association between American Cultural Identification and smoking abstinence is statistically significant) corresponds to Mexican Cultural Identification scores of approximately 4.25 (demarcated in Fig. 1A by the vertical gray dashed line) and higher. As depicted in Fig. 1A, at and above this value of Mexican Cultural Identification scores (encompassed by the grey shaded region), the conditional effect of American Cultural Identification is positive, indicating that higher American Cultural Identification scores are associated with greater likelihood of abstinence. Furthermore, the size of the conditional effect increases with increasing Mexican Cultural Identification scores. Figure 1B depicts the probabilities of abstinence predicted by American Cultural Identification at values below and within the region of significance. At Mexican Cultural Identification scores below the region of significance, the predicted probability of abstinence is moderate and fluctuates very little across American Cultural Identification scores. At Mexican Cultural Identification scores within the region of significance, predicted probability of abstinence increases rapidly with increasing American Cultural Identification scores. Table 2 Summary of significant interaction effects Predictor  Estimate (SE)  p-value  Age  0.02 (0.03)  .48  Male  1.49 (0.61)  .01  High school diploma/GED  −0.57 (0.61)  .35  Employed  0.09 (0.57)  .88  Income  0.07 (0.11)  .55  Not U.S.-born  −0.34 (0.72)  .64  ≤5 min to first cigarette of day  −1.15 (0.59)  .05  Cigarettes per day  −0.01 (0.03)  .61  American Cultural Identification  −3.23 (1.59)  .04  Mexican Cultural Identification  −3.91 (1.44)  .01  Mexican × American Cultural Identification  0.97 (0.39)  .01  Age  0.02 (0.03)  .46  Male  −1.37 (1.55)  .38  High school diploma/GED  −0.65 (0.63)  .31  Employed  0.09 (0.60)  .88  Income  0.04 (0.12)  .73  Not U.S.-born  0.02 (0.80)  .98  ≤5 min to first cigarette of day  −1.11 (0.60)  .07  Cigarettes per day  −0.02 (0.03)  .59  English Proficiency  −0.06 (0.39)  .87  Gender × English Proficiency  1.04 (0.51)  .04  Predictor  Estimate (SE)  p-value  Age  0.02 (0.03)  .48  Male  1.49 (0.61)  .01  High school diploma/GED  −0.57 (0.61)  .35  Employed  0.09 (0.57)  .88  Income  0.07 (0.11)  .55  Not U.S.-born  −0.34 (0.72)  .64  ≤5 min to first cigarette of day  −1.15 (0.59)  .05  Cigarettes per day  −0.01 (0.03)  .61  American Cultural Identification  −3.23 (1.59)  .04  Mexican Cultural Identification  −3.91 (1.44)  .01  Mexican × American Cultural Identification  0.97 (0.39)  .01  Age  0.02 (0.03)  .46  Male  −1.37 (1.55)  .38  High school diploma/GED  −0.65 (0.63)  .31  Employed  0.09 (0.60)  .88  Income  0.04 (0.12)  .73  Not U.S.-born  0.02 (0.80)  .98  ≤5 min to first cigarette of day  −1.11 (0.60)  .07  Cigarettes per day  −0.02 (0.03)  .59  English Proficiency  −0.06 (0.39)  .87  Gender × English Proficiency  1.04 (0.51)  .04  Bold indicates estimate that is statistically significant. View Large Table 2 Summary of significant interaction effects Predictor  Estimate (SE)  p-value  Age  0.02 (0.03)  .48  Male  1.49 (0.61)  .01  High school diploma/GED  −0.57 (0.61)  .35  Employed  0.09 (0.57)  .88  Income  0.07 (0.11)  .55  Not U.S.-born  −0.34 (0.72)  .64  ≤5 min to first cigarette of day  −1.15 (0.59)  .05  Cigarettes per day  −0.01 (0.03)  .61  American Cultural Identification  −3.23 (1.59)  .04  Mexican Cultural Identification  −3.91 (1.44)  .01  Mexican × American Cultural Identification  0.97 (0.39)  .01  Age  0.02 (0.03)  .46  Male  −1.37 (1.55)  .38  High school diploma/GED  −0.65 (0.63)  .31  Employed  0.09 (0.60)  .88  Income  0.04 (0.12)  .73  Not U.S.-born  0.02 (0.80)  .98  ≤5 min to first cigarette of day  −1.11 (0.60)  .07  Cigarettes per day  −0.02 (0.03)  .59  English Proficiency  −0.06 (0.39)  .87  Gender × English Proficiency  1.04 (0.51)  .04  Predictor  Estimate (SE)  p-value  Age  0.02 (0.03)  .48  Male  1.49 (0.61)  .01  High school diploma/GED  −0.57 (0.61)  .35  Employed  0.09 (0.57)  .88  Income  0.07 (0.11)  .55  Not U.S.-born  −0.34 (0.72)  .64  ≤5 min to first cigarette of day  −1.15 (0.59)  .05  Cigarettes per day  −0.01 (0.03)  .61  American Cultural Identification  −3.23 (1.59)  .04  Mexican Cultural Identification  −3.91 (1.44)  .01  Mexican × American Cultural Identification  0.97 (0.39)  .01  Age  0.02 (0.03)  .46  Male  −1.37 (1.55)  .38  High school diploma/GED  −0.65 (0.63)  .31  Employed  0.09 (0.60)  .88  Income  0.04 (0.12)  .73  Not U.S.-born  0.02 (0.80)  .98  ≤5 min to first cigarette of day  −1.11 (0.60)  .07  Cigarettes per day  −0.02 (0.03)  .59  English Proficiency  −0.06 (0.39)  .87  Gender × English Proficiency  1.04 (0.51)  .04  Bold indicates estimate that is statistically significant. View Large Fig. 1. View largeDownload slide Follow up of the interaction between American and Mexican Cultural Identity. (A) Johnson-Neyman plot of the conditional effect. Black solid line = conditional effect as a function of Mexican Cultural Identity; black dotted lines = upper and lower 95% confidence intervals; gray area = region of significance; gray dashed line = point of demarcation for region of significance. (B) predicted probabilities of abstinence at two scores of Mexican Cultural Identity. MCI = Mexican Cultural Identity score; ns = not significant. Fig. 1. View largeDownload slide Follow up of the interaction between American and Mexican Cultural Identity. (A) Johnson-Neyman plot of the conditional effect. Black solid line = conditional effect as a function of Mexican Cultural Identity; black dotted lines = upper and lower 95% confidence intervals; gray area = region of significance; gray dashed line = point of demarcation for region of significance. (B) predicted probabilities of abstinence at two scores of Mexican Cultural Identity. MCI = Mexican Cultural Identity score; ns = not significant. Results for Spanish Proficiency The interaction of English Proficiency and Spanish Proficiency on abstinence was not statistically significant (b = 0.42, SE b = 0.37, p = .25). Hypothesis 2: Greater acculturation in the Mexican-oriented domains would be associated with lower likelihood of cessation, and greater acculturation in the American-oriented domains would be associated with greater likelihood of cessation among men but not among women. Results for cultural identification Interaction tests of gender with each cultural identification scale were not significant (b = 0.63, SE b = 0.59, p = .29 for American Cultural Identification; b = −0.18, SE b = 0.69, p = .79 for Mexican Cultural Identification). Results for language proficiency The interaction of gender and English Proficiency was statistically significant (b = 1.04, SE b = 0.51, p = .04; see Table 2 for a summary of the full model), Follow-up analyses of the significant interaction effect indicated that English Proficiency was associated with likelihood of abstinence among men but not among women. Among men, a one-point increase in English Proficiency was associated with over a 2.5-fold increase in the odds of abstinence (men: adjusted odds ratio [AOR] = 2.66, 95% CI = 1.27–5.58; cf. women: AOR = 0.94, 95% CI = 0.44–2.0). Predicted probabilities of abstinence by English Proficiency scores for men and women are depicted in Fig. 2. The interaction of gender and Spanish Proficiency was not statistically significant (b = −1.82, SE b = 0.96, p = .06). Fig. 2. View largeDownload slide Predicted probabilities of abstinence by English Proficiency. ns = not significant. Fig. 2. View largeDownload slide Predicted probabilities of abstinence by English Proficiency. ns = not significant. Post Hoc Analyses Two post hoc analyses were conducted in light of the current findings. As the planned analyses involving Spanish Proficiency were not significant, we ran a model containing only the lower order terms to examine whether Spanish Proficiency had a unique association with abstinence. There was no significant relationship between Spanish proficiency and abstinence (b = −0.59, SE b = 0.40, p = .14). To examine Hypothesis 3, that accounting for cultural identification would attenuate the relationships between language proficiency and abstinence, we examined a model that included both the interaction term of gender and English Proficiency, and interaction term of American and Mexican Cultural Identification, as well as their lower order terms. Both interaction terms remained significantly associated with abstinence (Gender × English Proficiency, b = 1.18, SE b = 0.53, p = .02; American Cultural Identification × Mexican Cultural Identification, b = 1.10, SE b = 0.41, p = .008). Discussion To the best of our knowledge, the current study is the first to examine multiple domains and dimensions of acculturation for their independent and synergistic associations with smoking cessation among Latino adults engaged in a quit attempt. Language proficiency was assessed separately for English and Spanish, and cultural identification was assessed separately for American and Mexican cultural orientations. Among individuals with high Mexican self-identification, higher American self-identification was associated with greater likelihood of abstinence. Individuals with high Mexican self-identification and high American self-identification—indicative of biculturalism—had the highest likelihood of successful cessation. Individuals with strong Mexican self-identification but low American self-identification were most vulnerable to cessation failure. The current study also demonstrated a gender-differentiated association of English Proficiency with smoking abstinence. Consistent with previous research [32], higher English Proficiency was associated with increased likelihood of abstinence among men but not women. These observed associations were significant above and beyond sociodemographics and tobacco dependence, and persisted even when examining both significant interaction terms and their lower order terms in a single analysis. Cultural Identification and Smoking Cessation Study results regarding the self-identification domains of acculturation are consistent with current hypotheses and extant research demonstrating the benefits of a bicultural orientation. However, because American Cultural Identification was not associated with cessation among persons with low Mexican Cultural Identification, results might also suggest that efforts to understand how acculturation toward American culture influences smoking cessation may only be relevant to U.S. Latinos who also have very strong ties to their Latino cultural identity. This may include Latinos who are immigrants to the USA or U.S.-born Latinos who were reared and/or live in environments that strongly promote Latino cultural identity. Although the current study cannot directly speak to the process of cultural change, the findings bring forth the hypothesis that for persons with an already-strong Latino cultural self-identification, the factors that explain the relation between a bicultural self-identification and cessation have more to do with protective factors associated with the adoption of an American cultural self-identification than with protective factors associated with maintaining a strong Latino cultural identification. Research in acculturation psychology identifies some factors associated with a bicultural orientation that may account for the relation between a bicultural orientation and smoking cessation. For example, a bicultural orientation has been found to be positively associated with psychological well-being broadly defined [45, 46, 47], self-esteem, better sociocultural competence [45, 48, 49], and greater social support networks [47], and negatively associated with depressive symptoms [49–51]. Any of these psychosocial factors may directly or indirectly (e.g., through other known determinants of cessation, such as self-efficacy or motivation) affect one’s likelihood of successful cessation. It should be noted that it is not known whether biculturalism leads to these benefits or vice versa; therefore, it is also unknown whether biculturalism per se, could be causally linked to cessation. Importantly, reliance on the benefits of biculturalism as the sole explanation for these findings applies a cultural deficit model [52]. Furthermore, the practical benefits of biculturalism may be limited in their impact on the advancement of smoking cessation interventions as most of the purported mechanisms are already targets of existing interventions (e.g., negative effect, social support, self-efficacy), and specific cultural factors (e.g., cultural identification) may either not be amenable to intervention or raise issues regarding the ethics or desirability of change efforts. To avoid a cultural deficits model, it may be more useful to interpret results within a person-in-context framework. Thus, it may be less useful to ask “what is it about persons that might have influenced differential cessation outcomes?” and more useful to ask “what is it about the broader context, including the intervention itself, which might have influenced differential cessation outcomes across persons?” For example, the likelihood of cessation was less favorable among persons with high Mexican self-identification unless they also had high American self-identification. Previous research has demonstrated that higher levels of discrimination are associated with a lower likelihood of cessation among Mexican origin smokers [53]. Therefore, it may be that larger societal problems that disadvantage particular subgroups of Mexican origin smokers could account for the findings. Similarly, it is possible that the intervention may have been better suited to address certain needs or preferences of persons with high American self-identification compared with those of persons with a more “monocultural” Mexican self-identification. Thus, an important next step might be to identify those aspects of the intervention (e.g., its components, materials, delivery, setting, messages, targets), that did and did not resonate with one’s cultural identifications, and gather knowledge from the priority population on how to improve attention to culturally relevant factors within an intervention [54–57]. Such research would lay the groundwork for the development of more culturally responsive—and thus potentially more effective—smoking cessation interventions. Language Proficiency and Smoking Cessation Language proficiency falls within the behavioral domain of acculturation, and the sociodemographic variables used as proxies for acculturation in Castro et al. [32] are most highly associated with the behavioral domain [12] (this is also demonstrated in the bivariate associations in Table 1). Thus, the current findings regarding English proficiency replicate those of Castro et al. The current study expands upon these previous findings in that it separates the effects of English and Spanish language proficiencies. In contrast to current hypotheses, cultural identification did not account for the associations of language proficiency with abstinence. When discussing similar findings regarding relations between language proficiency and psychosocial adjustment among Asian American college students, Kang et al. [58] noted that language is a major mechanism through which cultural information is exchanged. That is, language use or proficiency (much like other common demographic proxies of acculturation; e.g., nativity, years residing in the USA, proportion of life spent in the USA) may serve as indicators of one’s level of exposure to or “immersion” in the societal culture with which the language is associated. Thus, greater English language proficiency may facilitate more exposure to societal influences on behavior. Importantly, this explanation differs from previous speculation on the relationship between acculturation and smoking behavior in that previous explanations have conceptualized the relation between proxies of behavioral acculturation and smoking behavior as spurious, likely accounted for by changes in cultural identity and values. Kang et al. imply that language usage exerts indirect effects on outcomes by way of increasing exposure to societal and cultural determinants of those outcomes. In the context of smoking cessation, there may be culturally relevant American societal factors that are of particular relevance to Latino smokers, and greater exposure to these societal factors may facilitate quitting among Latino men. As such, extant explanatory models that implicate social norms may still be important avenues of research to pursue. Whether or not social norms toward men’s smoking cessation differ cross-culturally remains to be empirically investigated. More broadly, findings regarding language proficiency suggest a continued need to identify social/societal contextual factors that may facilitate or impede cessation efforts among Latino smokers, and the need to understand the process that determines their particular relevance to Latino men. Limitations and Conclusion The current findings are novel and in need of corroboration, particularly in the context of study limitations. For example, the current study focused on language proficiency rather than behavioral acculturation more broadly. Also, some conceptualizations of biculturalism emphasize integration of cultural identities rather than simply high acculturation in both directions [45], and this approach to biculturalism could not be examined here. Given the importance of gender in studies on acculturation and smoking, a highly worthwhile set of additional analyses would have been to examine the three-way interaction of gender and measures of each direction of acculturation. Although these analyses (not shown) were null, their contribution to the current study was limited due to the small sample size and subsequent risk of Type II error. Although a focus on Mexican-origin smokers avoids the pitfalls of either treating Latinos as a homogenous population or of gathering data from multiple Latino subgroups in numbers too small for meaningful analyses within or between groups, this approach limits generalizability. The current study had numerous other eligibility criteria that may further limit generalizability (14 inclusion/exclusion criteria in total). Because the outcome of interests was measured at only two time points, the current study was limited to a random intercept/fixed slope growth factor model. Therefore, the current study was unable to examine predictors of individual trajectories of abstinence over time. Finally, as there are no accepted methods for pooling indices of model fit in the case of multiple imputation, the overall fit of the estimated models could not be evaluated. However, it is important to note that current analyses were not intended to find an optimal set of empirical predictors, but rather to test hypotheses about the interaction term in a given model, holding all other predictors constant. Nevertheless, the current study’s results reflect recent conceptualizations of the acculturation construct [10] as a set of multiple related, but distinct, factors with the potential for unique associations with a given behavior. As such, the current findings underscore the practical and theoretical importance of directly modeling the bidirectional and multidimensional nature of the acculturation construct. Supplementary Material Supplementary material is available at Annals of Behavioral Medicine online. Acknowledgements The data utilized in the current study were part of a larger project funded by the National Institute of Minority Health and Health Disparities (NIMHD; P60MD000503). Preparation of this manuscript was funded in part by grants from the National Cancer Institute (K01CA157689), NIMHD (R00MD010648, R21MD011431), and American Cancer Society (MRSG-15-018-01-CPPB). The contents of this manuscript are solely the responsibility of the authors and do not represent the official views of the funding agencies. Compliance with Ethical Standards Authors’ Statement of Conflict of Interest and Adherence to Ethical Standards None of the authors any conflicts of interest pertaining to this work. Authors’ Contributions All authors have made substantial contributions to the study and have approved of the final manuscript. Primary Data Neither all nor parts of this manuscript have been previously published or presented, and the manuscript is not currently submitted elsewhere for review. Ethical Approval All study procedures were approved by the Institutional Review Board of the University of Texas MD Anderson Cancer Center. 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Annals of Behavioral MedicineOxford University Press

Published: May 9, 2018

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