1. The University of Arizona HealthCare Partnership April 9, 2013 “¡Adios Tabaco!” Counseling for Success Cultural Variables Impact Treatment Effectiveness

2.  Describe the current demographic trend of Hispanic/Latino population in the U.S.  Identify the use of tobacco products among Hispanic/Latino people living in the U.S.  Recognize Hispanic/Latino cultural values that influence counseling interventions for the treatment of nicotine addiction  Practice a motivational script as it applies to a Hispanic/Latino person who uses tobacco Learning Objectives

3.  I’m an acculturated Hispanic – I eat burgers and pizza, drink carbonated soft drinks, and smoke cigarettes. Wait, Wait, Don’t Tell Me Agree? Disagree?

4.  Hispanic—those living in the U.S., who were born in, or their families immigrated from one of the Spanish- speaking Latin American countries or Spain.  Latino—is used interchangeably with the term Hispanic. Some consider it to be more politically correct as it relates to ancestors in the Americas versus Spain.  Latino can include Latin Americans who are NOT Spanish speaking.  Other ethnic references may include:  Latin American  Spanish-speaking  Latin  Spanish  Raza  Chicano Hispanic? Latino? The U.S. Census Bureau uses the term Hispanic as the name of an ethnic group rather than a race. Hispanics, Latinos all belong to the human race. Cultural values prompt Hispanics to self-identify as members of the same ethnic group. The Healthcare Partnership uses the terms Hispanic/Latino interchangeably. The U.S. Census Bureau uses the term Hispanic as the name of an ethnic group rather than a race. Hispanics, Latinos all belong to the human race. Cultural values prompt Hispanics to self-identify as members of the same ethnic group. The Healthcare Partnership uses the terms Hispanic/Latino interchangeably.

5. Cultural Variables Impact Treatment Success

6.  Hispanics have the second highest prevalence rate of smoking in the U.S. Wait, Wait, Don’t Tell Me.. Agree? Disagree?

7. U.S. Hispanics At-A-Glance

8.  Education  24% do not graduate from high school.  Income  The median income for Hispanics in the United States in 2011 was $39,000, compared to $54,400 for non-Hispanic white.  Standard of Living  25.3% living below the Federal poverty level. [Sources: Pew Hispanic Center; US DHHS] U.S. Hispanics At-A-Glance

9.  Health Insurance U.S. Hispanics At-A-Glance

10.  Language  Over 75% of Hispanics age 5 and older speak Spanish at home. U.S. Hispanics At-A-Glance

11.  In general, when compared with non-Hispanic whites, Hispanics smoke more cigarettes. Wait, Wait, Don’t Tell Me… Agree? Disagree?

12.  12.9% of adult Hispanics/Latinos smoke cigarettes.  17% of Hispanic men smoke, 8.6% of Hispanic women smoke  Tend to be non-daily or light and intermittent smokers (depends largely on subculture).  As Hispanic/Latino women become more acculturated, rate of smoking increases. [Source: Nicotine and Tobacco Research] Hispanics\Latinos Tobacco Use

13. Disparity of Smoking Prevalence Among Hispanic Subgroups [Source: American Lung Association, 2008]

14.  Those who are low literate in English have limited exposure to tobacco control information, resources, media messages and treatment options.  Hispanic/Latino populations are the target of intensive tobacco industry marketing efforts. [Sources: CDC Office on Smoking and Health; Pew Hispanic Center] Hispanics/Latinos at Higher Risk for Tobacco Use

15.  Hispanic/Latino workers tend to have more exposure to secondhand smoke in the workplace. Hispanics/Latinos at Higher Risk for Tobacco Use [Sources: CDC Office on Smoking and Health; no-smoke.org]

16.  10 Leading Causes of Death for Hispanics/Latinos in 2011:  1. Cancer  2. Heart Disease  3. Unintentional Injuries  4. Stroke  5. Diabetes  6. Chronic Liver Disease and Cirrhosis  7. Chronic Lower Respiratory Diseases  8. Influenza and Pneumonia  9. Homicide  10. Nephritis, Nephrotic Syndrome & Nephrosis [Source: CDC Office on Minority Health] Disease Management and Tobacco Use

17.  Collectivism  Simpatía  Familism  Respeto  Fatalism  Personalismo  Time Orientation  Humor  Machismo Cultural Values That Impact Treatment of Nicotine Addiction [Source: HealthCare Partnership OnLine LearningCenter]

18.  Collectivism—prefer interpersonal relationships with in-groups that are nurturing, loving, intimate and respectful.  Simpatia—need for behaviors that promote smooth and pleasant social relationships.  Familisim—involves strong identification with and attachment to nuclear and extended families. Cultural Values that Impact Treatment for Nicotine Addiction [Sources: CDC Office on Smoking and Health; no-smoke.org]

19.  Respeto—value conformity and obedience and support autocratic and authoritarian attitude from those in charge of organizations.  Fatalism—emphasizes that there is little an individual can do to alter fate.  Personalismo—feel comfortable when physically close to others. Cultural Values that Impact Treatment for Nicotine Addiction [Sources: CDC Office on Smoking and Health; no-smoke.org]

20.  Time Orientation—present-oriented that can translate into being late for appointments. Tend to be flexible in time orientation.  Humor—Hispanics enjoy laughter and comedy. Specifically, Mexicans laugh about adversity, about events that do not go their way and even about death and themselves in certain contexts. Cultural Values that Impact Treatment for Nicotine Addiction [Sources: CDC Office on Smoking and Health; no-smoke.org]

21.  Machismo—smoking may be seen as a “desirable” masculine behavior. Cultural Values that Impact Treatment for Nicotine Addiction [Sources: CDC Office on Smoking and Health; no-smoke.org]

22.  Hispanics who smoke are less likely than non- Hispanic whites who smoke to receive medication from a provider.  Maintain a higher intention to quit than non-Hispanic whites.  Hispanics are more likely to quit smoking than non- Hispanic whites.  Knowing the adverse effects of smoking, reading a pamphlet:  Health effects of cigarette smoke on family and children  Sensitivity to family criticism  Being a bad example to children  Tobacco effects on personal appearance  Cost of cigarettes Hispanics and Abstinence from Tobacco [Sources: CDC Office on Smoking and Health; no-smoke.org]

23.  High rates of smoke free housing may aide in quit attempts among Hispanics.  Hispanics who smoke daily are more likely to have a complete ban on household smoking (54.5%) in comparison to non-Hispanic white households (35.0%).  Congratulatory reinforcement from family and friends. Hispanics and Abstinence from Tobacco [Sources: CDC Office on Smoking and Health; no-smoke.org]

24. Impact of Cultural Values on Evidence-Based Interventions

26.  Motivational Interviewing: Technique? Attitude? Motivational Interviewing Scripting for Counseling Effectiveness

27.  Roll with resistance  Example – “You are not ready to quit smoking at this time?”  When to use – when an individual is expressing resistance.  Express empathy  Example – “You are worried that you may not be able to quit because all of your brothers and other relatives smoke?”  When to use – to demonstrate understanding and to address the individual’s core concern. Motivational Interviewing Scripting for Counseling Effectiveness

28.  Avoid argumentation  Example – “You do not see yourself quitting smoking at this time? What types of things are you willing to do to lower your blood pressure?”  When to use – to demonstrate understanding and to prevent creating relational resistance. Motivational Interviewing Scripting for Counseling Effectiveness

29.  Develop discrepancy  Example – “On the one hand, you have an important goal of lowering your blood pressure to prevent stroke and heart attack. On the other hand, your smoking raises your blood pressure and your risks of stroke. What are your thoughts?”  When to use – to create “change talk” without creating more resistance. Motivational Interviewing Scripting for Counseling Effectiveness

30.  Support self-efficacy  Example – “I am really glad to hear that you are thinking more about quitting. What has you thinking more about that?”  When to use – to reinforce both thoughts and actions regarding behavior change. Motivational Interviewing Scripting for Counseling Effectiveness

31.  A look over the fence  Example – “If you were to wake up tomorrow and you were no longer a smoker, what would you like about that?”  When to use – to encourage change talk and assisting the person in making the argument for the change—creates dissonance. Motivational Interviewing Scripting for Counseling Effectiveness

32.  The envelope  Example – “If I were to hand you an envelope, what would the message have to say inside for you to consider setting a quit date?”  When to use – to explore readiness for change. Motivational Interviewing Scripting for Counseling Effectiveness

33.  The “insurance card”  Example – “May I tell you what concerns me?”  When to use – to prevent “fixing” or “saving” the person. Motivational Interviewing Scripting for Counseling Effectiveness

34.  Hispanics are more likely to slip and relapse because:  Invited to smoke by friends or family  Invited to smoke at a party or other social activity  Feeling nervous, angry or worried  Having personal problems  Obstacles  … Inhibiting Motivation to Quit

35. ¡Trabajando juntos para mejorar salud! “¡ADIOS TABACO!”

36. Louise J. Strayer BSc, RN, MSc, lstrayer@email.arizona.edu 520-235-9908 HealthCare Partnership at The University of Arizona http://www.healthcarepartnership.org HealthCare Partnership Online Learning Center http://www.aztreattobacco.org