January 31, 2024 • 30 mins
PhD candidate Adrienne Lee discusses her article, “Acculturation level and change in cigarette consumption behaviors among diverse Hispanics/Latinos: the Hispanic Community Health Study/Study of Latinos,” published in the August 2023 issue (Vol. 84) of Annals of Epidemiology. In this study, the researchers explore the influence of language acculturation on smoking behaviors in the U.S. Hispanic/Latino population and provide insights to inform culturally tailored smoking prevention and cessation strategies for the community.
Read the full article here:
https://www.sciencedirect.com/science/article/pii/S1047279723000893
Episode Credits:
- Executive Producer: Sabrina Debas
- Technical Producer: Paula Burrows
- Annals of Epidemiology is published by Elsevier.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Patrick Sullivan (00:12):
Hello, you're listening to EPITalk
Paper, a monthly podcast fromthe Annals of Epidemiology.
I'm Patrick Sullivan,Editor-in-Chief of the journal,
and in this series we take youbehind the scenes of some of the
latest epidemiologic researchfeatured in our journal.
Today we're talking with Ms.
(00:34):
Adrienne Lee about her article"A Culturation Level and Change
in Cigarette ConsumptionBehaviors Among Diverse
Hispanics/ Latinos (00:40):
the Hispanic Community Health Study/ Study
of Latinos.
You can find the full articleonline in the August 2023 issue
of the journal at www.
annalsofepidemiology.
org.
So I want to introduce ourguest today.
Ms.
Adrienne Lee is a PhD candidatein Epidemiology in the Joint
Doctoral Program at theUniversity of California, San
(01:03):
Diego/S an Diego StateUniversity, and a recipient of
the National Institute onAging's Pre-to-Post-Doctoral
Transition to Aging ResearchAward.
Her research focuses on socialand structural determinants of
health and equitable aging inunderserved minority populations
.
Ms.
Lee, thank you so much forjoining us today.
Adrienne Lee (01:22):
Thank you, Patrick, for having me.
I'm looking forward to ourdiscussions.
Patrick Sullivan (01:26):
Great.
Well, let's jump in, because Ireally want to give people an
idea both of what your researchwas about, but also the problem
that you're trying to address.
So can you start out just bygiving me a little background on
the problem that you weretrying to address?
Why is this issue important?
Adrienne Lee (01:43):
Sure.
So the Hispanic/ Latinopopulation that's living in the
United States is growing and isprojected to increase by up to
50% in the next few decades, andas they live and age here in
the United States, it's going tobe important for us to better
understand the key factors thatinfluence modifiable health
(02:04):
behaviors like smoking, whichwe're interested in in our
current paper.
Smoking cigarettes is wellknown to cause cancer,
cardiovascular diseases andAlzheimer's diseases, among
other comorbidities, and thoseoutcomes also disproportionately
impact the Hispanic Latinopopulation, and so, despite
(02:27):
certain heritage groups having amuch higher burden of smoking
than the general population,Hispanic/ Latinos tend to
receive less cessation advice,and so if we aim to reduce the
smoking behaviors in thispopulation, with the ultimate
goal of improving their healthoutcomes as they age in the
(02:48):
United States, then we're goingto need to inform smoking
prevention and cessationstrategies that are culturally
tailored and effective for thiscommunity.
Patrick Sullivan (02:57):
So I think that's a great explanation of
why this is such an importantissue.
In the article, you reallyconsider acculturation level as
one of the potential socialdeterminants for smoking
behaviors.
What prompted you to look atacculturation as one of your
exposures?
Adrienne Lee (03:15):
So our group was interested in studying
acculturation level as a socialdeterminant of health, largely
in part because nearly everyimmigrant and child of
immigrants that is in the UnitedStates is going to have some
experience of acculturation, astwo or more cultures collide,
(03:36):
and so the process ofacculturation is a multi-
dimensional process in whichyou're retaining one's original
culture as well as adopting somenew aspects of your new culture
and the interaction of thoseprocesses.
And so there is evidence tosuggest that acculturation level
(03:57):
is associated with smokingbehaviors in the Hispanic/
Latino population, largely notedin women, where higher levels
of acculturation are actuallyassociated with higher odds of
smoking, whereas with men thosetend to be null.
Results are in the oppositedirection.
A lot of the research that hasbeen done to date looking at the
(04:22):
relationship betweenacculturation and smoking
behaviors has been donecross-sectionally, looking at
prevalence rates or quittingrates in the population and not
necessarily individual changesto smoking behaviors.
And so, as a goal of ours toultimately change and reduce the
(04:43):
smoking behaviors in thispopulation, we wanted to focus
on acculturation and the rolethat that plays, and I'll add
that some of the existing theoryas far as how acculturation may
change behaviors and impacthealth in the Hispanic/ Latino
population is through aninteraction with socioeconomic
(05:06):
status and as a proxy for socialmobility for this population
once they're in the UnitedStates, and so we really aimed
to delve a little bit furtherinto those relationships to
hopefully better inform thestrategies we use to modify
these behaviors.
Patrick Sullivan (05:23):
Right.
Well, your answer just sort ofsets up so perfectly where I
want to end with this, which isyou talked about the fact that
there have been somecross-sectional kind of designs,
but tell us about the studydesign that you use and the data
sources that you use to answerthese questions.
Adrienne Lee (05:39):
Sure.
So to address our researchquestions, we used data from the
Hispanic Community HealthSurvey/ Study of Latinos and
included participants whoidentified as current smokers at
the baseline visit.
We had two visits available forour study population in which
(05:59):
self-reported individual levelcigarette consumption data was
available.
Our primary exposure ofinterest was acculturation,
language acculturationspecifically, which was measured
using a short acculturationscale for Hispanics, and we used
primarily the language subscalebecause language explains most
(06:23):
of the variability inacculturation constructs and it
had the best psychometricproperties for our study sample.
We conducted analyses lookingat change in consumption
behaviors by comparing follow-upcigarette consumption behaviors
to baseline in linearregressions, and we also
(06:46):
measured quitting outcomes inlogistic regressions using those
individuals who were currentsmokers at baseline but who
endorsed no longer smoking attheir follow-up visit.
We further stratified ouranalyses and conducted subgroup
analyses by sex, educationalattainment and migration status,
(07:06):
and so we had about 2,000individuals in our final study
sample with two points ofcigarette consumption data
available, and we were able toreally look at those individual
level changes and theassociations between
acculturation and those smokingoutcomes.
Patrick Sullivan (07:25):
And about how far apart in time were the two
measures?
Adrienne Lee (07:30):
On average about seven years between the two
visits six and a half to sevenyears.
Patrick Sullivan (07:35):
It's quite a long interval to be able to get
the callback and, like, have ausable response rate.
So that's really interesting.
So so, now you have us allqueued up, what did you find?
What was the sort of keyfinding around this relationship
between acculturation andneither persistence or quitting
of smoking?
Adrienne Lee (07:51):
Sure.
So subgroup analyses were quiteinformative, and what we found
in our study is that among menwho were daily smokers, higher
levels of language acculturationwere associated with increased
cigarette consumption behaviors.
So over the course of thatseven-year period, on average
(08:13):
men increased by one cigaretteper day at those higher levels
of acculturation.
In our female sample we did notsee what we had been expecting.
We actually observed trendstowards declines in cigarette
consumption.
Additionally, when westratified our sample further by
(08:33):
educational attainment, we gotsome really interesting results
that weren't quite what we wereexpecting, and so we found that
among daily smokers, those whohad greater educational
attainment and higher levels oflanguage acculturation had a
much lower odds of quitting andtrended towards increased
(08:53):
cigarette consumption behaviors.
So our research does fill someimportant gaps in the literature
and provides some points foradditional research for us to
really delve into this further.
Patrick Sullivan (09:06):
Really interesting.
What do you make of thedifference between men and women
?
Sometimes we just say, like,that is what it is, and that
raises more questions Like doyou have any hypotheses based on
literature or other data?
Adrienne Lee (09:18):
So part of what could be explaining those sex
differences that we observed maybe the access and use of
healthcare services, whereasindividuals become more
acculturated as far as theirEnglish language use and their
(09:38):
ability to understand and intakeprevention or cessation
resources.
That might be consistent.
However, the sex differences ofwhether or not they're actually
accessing those resources anduptaking the services that are
being offered might be part ofthe explanation as to why we saw
these differences in ourfindings, compared to those
(10:01):
previous studies that looked atprevalence rates and sex
differences in prevalence rates.
Patrick Sullivan (10:07):
Yeah, you also had the difference between
previous studies that have doneprevalence based measures and
now you're doing somethingthat's longitudinal, and so I
think that study design alsodepending on what the sort of
patterns of use are, could alsogive you a different type of
data.
So that also might play in.
How did the data source measurecigarette consumption behaviors
(10:28):
?
Adrienne Lee (10:28):
So for daily and non-daily smokers, well,
everyone was asked whether ornot they had a history of
smoking and their lifetime and,if so, whether or not they were
current users.
And among those who werecurrent users, they were asked
whether they smoked daily ornon-daily.
And then, as far as consumption, they were asked specifically
(10:52):
how many cigarettes per day onaverage they consume as daily
smokers or as non-daily smokers.
Patrick Sullivan (11:00):
On the days that they do smoke, the average
number of cigarettes that areconsumed per day so I'm going to
just shout out to my Epi530class because we've been talking
about information bias andmisclassification.
So I just have to ask like doyou have any concern about
relying on self-reported data oncigarette consumption and sort
of what's known about potentialmisclassification?
Adrienne Lee (11:22):
Sure, and you know, self-reported measures
kind of inherently introduced.
These biases, and the ones thatwe're particularly concerned
with in this study, would besocial desirability bias and
that recall bias, you know,recalling over the past year the
average number of cigarettesthat were smoked.
I do believe that in thecurrent study those biases would
(11:48):
likely lead to under-reportingof consumed behaviors, where the
true consumption may likely behigher than what was actually
reported in the study.
And so in that sense, while thebias is there, I think we would
expect the results in theestimates to be still similar
(12:14):
changes, if not larger changesin the true data versus what was
reported in the study, and soin that sense we didn't do too
much to try to evaluate thatbias further.
But that is what we wouldanticipate in this context.
Patrick Sullivan (12:33):
Wonderful and uh- I am going to recommend this
to my Epi5 30 students becausethat's exactly the kind of
analysis we're working ondeveloping in class, so thank
you for that.
So, compared to what othershave found in terms of the
association of acculturation andchange in cigarette consumption
behavior, particularly amongHispanic/ Latino individuals,
(12:53):
how does what you found compareand why do you think it's the
same or different, or strongeror weaker?
Adrienne Lee (12:59):
Great question and so, as I mentioned, a lot of
what we found was differentfrom what has been published so
far in studying theseassociations, and so, where we
may have been expecting to findstronger associations in the
women that were included in ourstudy, what we found is that men
(13:21):
in fact had these associationsof higher acculturation level,
leading to increased consumptionbehaviors, and so, as we kind
of started to mention before,we're looking at individual
changes and there's a lot ofother factors that are going
into changing behaviors, asopposed to how someone is
(13:43):
behaving at any one given pointin time.
And within the scope of what wewere able to do in this study,
being one of the first studiesto really look at this
association, we had to keep itwithin the scope of our research
questions.
But some things to definitelyconsider, especially with our
findings of sex differences, are, you know, those access to
(14:07):
health care services orprevention services, and whether
or not those are actually beinguptaken by men or women and
what those drivers are in thoserelationships.
I think another thing that wefound that was different from
the literature and what we wereexpecting to see is that higher
educational attainment withhigher acculturation level was
(14:31):
associated with lower odds ofquitting, and I think that we
expect that with greateracculturation level, you may
have increased access toinformation and resources and
people who are facilitatinghealthier behaviors, and that's
not exactly what we see here.
(14:52):
We're seeing that this highereducation is either leading to
persistent or increased smokingbehaviors, and so really being
able to further study why thatwas the case and what is driving
that association I think isgoing to be an important next
step in the research focused onthe role of acculturation on
(15:15):
smoking behaviors for ourpopulation.
Patrick Sullivan (15:18):
Wonderful.
Well, we're going to turn nowfrom your research to understand
a little bit about how it cameabout, and this is we call
Behind the Paper, to try andunderstand a little bit more
about the process and whereeverybody doing this kind of
research were all people and sothose sort of humanistic aspects
of what we do.
So I'm just going to open up alittle discussion here.
(15:39):
First, respect for producingthis kind of really detailed
analysis and getting itpublished during your PhD
candidacy.
It's amazing work.
I wonder what was mostchallenging or maybe, if
anything, was frustrating aboutconducting this particular
research study.
So what was engaging andenjoyable?
What was more frustrating foryou?
Adrienne Lee (16:01):
Great question, and so I have to say that the
most challenging part of thisproject was also the most
engaging and enjoyable aspect ofit, which is that this study
cohort the study SOL (16:16):
Study of Latinos has a very robust
publication committee, and theyassigned subject matter experts
as co-authors to collaborate onthese papers, and they also have
an extensive review andapproval process for
(16:37):
publications using their data.
And so the challenge there being, as a PhD student at UC San
Diego and San Diego StateUniversity, the competing
priorities that we have whilemanaging a manuscript with so
many co-authors and managing theexpectations and the timelines
(17:00):
of the committee within areasonable time frame and
ensuring that we're enlistingall of the feedback and
expertise from those co-authorsin developing this paper.
I do think that ultimately, thatwas also a rewarding experience
to get exposure, of managingand leading a project that has
(17:20):
multiple stakeholders andco-authors involved in it, and
ultimately it resulted in a muchhigher quality and
well-informed publication, andso that engagement and
collaboration was definitelyenjoyable in the end, and I will
say also that, when you keep inmind, the bigger picture of
(17:43):
this publication committee andwhy they're doing their due
diligence to ensurecollaboration and to ensure high
quality, results are beingdisseminated from this study
ultimately comes back to thecommunity and ensuring that the
results that are beingdisseminated from this study are
(18:04):
having a positive impact andare not doing harm to the
individuals that we're aiming toserve, and that we're not
unintentionally eitherperpetuating stereotypes or
introducing stigma for thispopulation that we're ultimately
trying to serve.
And so, while it waschallenging at times, I think it
(18:27):
was also very much the mostengaging and enjoyable aspect of
the process.
Patrick Sullivan (18:33):
That's Patrick Sullivan
heard of that mechanism wherethere's this intentional
involvement of people in theresearch, in the dissemination,
in such a structured way.
So it's just really exciting tohear about that.
I mean, I wonder in thatrespect, like both the
perspective of participants butalso like academic partners,
(18:53):
researchers why is it importantto have that inclusion and
representation of the communityand Hispanic/L atino targeted
research or practice andprogramming?
How does that affect what comesout of the utility of it?
Adrienne Lee (19:08):
Sure, and so I'll start by saying I may have
buried the lead here.
I am Hispanic/ Latina myself.
I'm a first generation Dominicanborn in the US, and so, on a
personal level, professionally,this was truly one of the first
experiences that I've had wherethe majority of my collaborators
(19:30):
were Hispanic/ Latino, and thatdoesn't just include my
co-authors but the, you know,the people that were on the
special interest working groupsand in the publication committee
.
And so, from a personal level, Ithink just seeing that level of
representation and anaffirmation that there are
(19:52):
spaces at the table not just forHispanic/ Latinos but for
Latinas in particular, and thatour perspectives and our
contributions are important andvalued, I think is really
important to see at that levelfor myself and just as I
continue to aspire in my futurecareer goals.
(20:15):
But then, from a public healthperspective, you know it's
integral to health equity toinvolve the people from the
community in all of the phasesof research, from
conceptualization through todissemination, to ensure not
only that the interests of thepopulation are being considered
(20:36):
and incorporated, but that theircultural norms and perceptions
and those types of nuances arebeing incorporated into the
research.
That's being done with theultimate goal of having
effective interventions thatmake the intended impact for the
most vulnerable people in ourcommunities.
(20:57):
So critically important to havethat level of representation
throughout the process and inresearch in general.
Patrick Sullivan (21:05):
Thank you for that.
I'm going to ask kind of arelated question just about your
own journey to public healthand you're now in a place of
health equity research, which Ithink is a new recognition and a
critical recognition of abranch of these kinds of studies
.
How did your own backgroundshape your professional goals
and your interest in these areas?
Adrienne Lee (21:26):
So I will say that my early on in my career
trajectory I was interested inattending medical school, and so
a lot of my experience aftergraduating from college was in a
clinical setting, and I thinkmy interest really pivoted from
(21:47):
individual level care to more ofthis population level care when
I was working as a clinicaltrials research coordinator at a
cancer center, and in this roleI was very closely working with
and involved in the care andtreatment of all of the study
participants that we wereenrolling in my trials.
(22:09):
And so two things really startedto stick out to me, which is
that one the vast majority ofthe participants we enrolled in
our trials were white, nonHispanic and socioeconomically
from middle and upper classes,and the very few and far between
(22:31):
black and Hispanic participantsthat we did enroll I found
struggled with study adherenceand often had not as favorable
of health outcomes as some ofthe other participants.
So this really started to bloommy curiosity and I asked them
(22:52):
you know what are the reasonsthat we're not seeing you on?
You know your scheduled studyvisit days and nine times out of
10.
Very much socioeconomic factors, things like transportation or
unable to get off of work, oryour health insurance wasn't
(23:12):
covering the services for thestudy, and so I really saw this
spectrum of participants whowere either able to fly into the
city weekly for a 30 minutefollow up visit.
To the other end, you know,people who had to coordinate
(23:33):
transportation through theirchurch services and plan it a
month in advance, and so thesekinds of inequities just became
very apparent to me and led meinto more of a public health
space and to wanting to havemore of a population based
impact for those individuals whowere struggling the most in our
(23:56):
society, to try and get them tohave equitable outcomes when
we're trying to treat or preventany of the various health
outcomes that we're interestedin.
Patrick Sullivan (24:07):
Yeah, you raise such important points and
I think we see the same thing inAtlanta with research
participants and it's a part ofit is reflecting this sort of
underlying inequities, but froma research perspective, it's
also that exactly the samethings which is the reason that
some people don't come isbecause of transportation issues
(24:30):
are needing to work and thesort of socio economically
driven factors.
So two things.
That one is just the dignityand the respect of trying to
make sure that each person getswhat they need to be able to
meaningfully participate.
So for us that means some folksneed Uber rides to get to the
clinic visit and some folksdon't, and so we provide that
(24:50):
and we moved our research clinicto be like a block away from a
Marta station, which is oururban train, in a subway system
to try and minimize thosebarriers.
So it's both about equity andrespect for individuals, but
it's also about the inclusion ofdiverse participants.
So there is also, from an epipoint of view, a selection bias
(25:11):
or retention bias that I thinkis really important In this case
, like thinking a next layerdown about how we, the equity
lens of saying how do we make itequally easy for everyone to
participate, which doesn't meaneverybody needs to get the same
thing, but it means that we'retailoring how we support people
participating in research tomeet their needs.
It's both equitable and right,but it's also better for
(25:32):
research and that we don't havesome of those selection biases
or retention biases, you know,if we take a one size fits all
approach to how we supportpeople in research, so it's
interesting and analogous in adifferent population here.
So last is someone who is inyour PhD program.
I want to do two things.
One is you're going to bemoving towards finishing and
(25:53):
where do you want to head nextfor all of the folks who listen
to, who may be have postdocpositions and junior faculty
positions like where do you wantto head and what's the next
step for you when you're done?
Adrienne Lee (26:04):
Thank you for that question, and so I will
have a plug that the NationalInstitute on Aging Award that
I've received this year tofinish my dissertation work as
well as transition me into apostdoctoral position, is really
one that is presenting me witha tremendous opportunity.
(26:25):
I think the next phase in myprofessional development will be
one to get additional trainingin additional social
epidemiology, but alsospecifically in implementation
science and really trying tokind of understand how, in with
these evidence based practices,can we effectively translate
(26:50):
these interventions intopopulations that we know are at
great risk for certain agingoutcomes, and so getting that
type of exposure and experiencesprimarily what I am looking for
in this next phase.
I have a few institutions thatare at the top of my list, but
(27:11):
you can't reveal, all will be.
Yeah, yeah, we'll go through theappropriate processes and
ensuring that, you know, we endup in a place that has the
resources to really continue tosupport my ultimate research
goals.
Patrick Sullivan (27:27):
One last question.
You're in a doctoral program.
You've survived, you've thrived, you've gotten this cool pre to
post doctoral transition grant.
What piece of advice would youhave for students are coming
into their doctoral program,based on what your experience
has been?
Adrienne Lee (27:43):
So my advice to incoming students would be to
regularly reflect and update youknow an individual development
plan and to really be sure thatthey have goals in mind for the
types of training or experiencesthat they want to gain during
(28:05):
this program, and seeking outthose opportunities, or creating
those opportunities, so thatyou can ensure that you're
getting what you want out ofthis program.
As I mentioned, there's a lotof competing priorities when
you're in a PhD program.
It's not just the coursework orthe qualifying exams you know,
(28:25):
your paid research, but also theside projects that you
participate in, and so managingyour priorities and ensuring
that you are getting what youwant to get out of this
opportunity with the time thatyou have.
Patrick Sullivan (28:41):
But great advice and thank you for sharing
that.
So do you have any finalthoughts that you'd like to
share with our listeners?
Adrienne Lee (28:49):
Just that- as public health professionals, we
have, hopefully, a shared goaland interest to improve the
health and well being ofeveryone that lives within our
society, and not just toincrease the lifespan but really
increase the health span ofindividuals living within our
(29:11):
communities, and so ensuringthat we're taking this health
equity approach and being ableto identify those in our
communities who need the mosthelp to really be able to live
happy and healthy long liveswould be my public service
announcement for the listenerstoday.
Patrick Sullivan (29:33):
And what a great way to wrap up our episode
.
Thank you again so much forjoining us today.
It was really a pleasure tohave you and we'll hope to see
much more of your work at Annalsof Epidemiology and the other
places that you publish it inthe future.
Congratulations.
Adrienne Lee (29:48):
Thank you so much for having me today.
Patrick Sullivan (29:50):
I'm your host, Patrick Sullivan.
Thanks for tuning in to thisepisode and see you next time on
EPITalk, brought to you byAnnals of Epidemiology, the
official journal of the AmericanCollege of Epidemiology.
For a transcript of thispodcast or to read the article
featured in this episode andmore from the journal, you can
visit us online at www.
(30:12):
annalsofepidemiology.
org.
Hello, you're listening to EPITalk
Paper, a monthly podcast fromthe Annals of Epidemiology.
I'm Patrick Sullivan,Editor-in-Chief of the journal,
and in this series we take youbehind the scenes of some of the
latest epidemiologic researchfeatured in our journal.
Today we're talking with Ms.
(00:34):
Adrienne Lee about her article"A Culturation Level and Change
in Cigarette ConsumptionBehaviors Among Diverse
Hispanics/ Latinos (00:40):
the Hispanic Community Health Study/ Study
of Latinos.
You can find the full articleonline in the August 2023 issue
of the journal at www.
annalsofepidemiology.
org.
So I want to introduce ourguest today.
Ms.
Adrienne Lee is a PhD candidatein Epidemiology in the Joint
Doctoral Program at theUniversity of California, San
(01:03):
Diego/S an Diego StateUniversity, and a recipient of
the National Institute onAging's Pre-to-Post-Doctoral
Transition to Aging ResearchAward.
Her research focuses on socialand structural determinants of
health and equitable aging inunderserved minority populations
.
Ms.
Lee, thank you so much forjoining us today.
Adrienne Lee (01:22):
Thank you, Patrick, for having me.
I'm looking forward to ourdiscussions.
Patrick Sullivan (01:26):
Great.
Well, let's jump in, because Ireally want to give people an
idea both of what your researchwas about, but also the problem
that you're trying to address.
So can you start out just bygiving me a little background on
the problem that you weretrying to address?
Why is this issue important?
Adrienne Lee (01:43):
Sure.
So the Hispanic/ Latinopopulation that's living in the
United States is growing and isprojected to increase by up to
50% in the next few decades, andas they live and age here in
the United States, it's going tobe important for us to better
understand the key factors thatinfluence modifiable health
(02:04):
behaviors like smoking, whichwe're interested in in our
current paper.
Smoking cigarettes is wellknown to cause cancer,
cardiovascular diseases andAlzheimer's diseases, among
other comorbidities, and thoseoutcomes also disproportionately
impact the Hispanic Latinopopulation, and so, despite
(02:27):
certain heritage groups having amuch higher burden of smoking
than the general population,Hispanic/ Latinos tend to
receive less cessation advice,and so if we aim to reduce the
smoking behaviors in thispopulation, with the ultimate
goal of improving their healthoutcomes as they age in the
(02:48):
United States, then we're goingto need to inform smoking
prevention and cessationstrategies that are culturally
tailored and effective for thiscommunity.
Patrick Sullivan (02:57):
So I think that's a great explanation of
why this is such an importantissue.
In the article, you reallyconsider acculturation level as
one of the potential socialdeterminants for smoking
behaviors.
What prompted you to look atacculturation as one of your
exposures?
Adrienne Lee (03:15):
So our group was interested in studying
acculturation level as a socialdeterminant of health, largely
in part because nearly everyimmigrant and child of
immigrants that is in the UnitedStates is going to have some
experience of acculturation, astwo or more cultures collide,
(03:36):
and so the process ofacculturation is a multi-
dimensional process in whichyou're retaining one's original
culture as well as adopting somenew aspects of your new culture
and the interaction of thoseprocesses.
And so there is evidence tosuggest that acculturation level
(03:57):
is associated with smokingbehaviors in the Hispanic/
Latino population, largely notedin women, where higher levels
of acculturation are actuallyassociated with higher odds of
smoking, whereas with men thosetend to be null.
Results are in the oppositedirection.
A lot of the research that hasbeen done to date looking at the
(04:22):
relationship betweenacculturation and smoking
behaviors has been donecross-sectionally, looking at
prevalence rates or quittingrates in the population and not
necessarily individual changesto smoking behaviors.
And so, as a goal of ours toultimately change and reduce the
(04:43):
smoking behaviors in thispopulation, we wanted to focus
on acculturation and the rolethat that plays, and I'll add
that some of the existing theoryas far as how acculturation may
change behaviors and impacthealth in the Hispanic/ Latino
population is through aninteraction with socioeconomic
(05:06):
status and as a proxy for socialmobility for this population
once they're in the UnitedStates, and so we really aimed
to delve a little bit furtherinto those relationships to
hopefully better inform thestrategies we use to modify
these behaviors.
Patrick Sullivan (05:23):
Right.
Well, your answer just sort ofsets up so perfectly where I
want to end with this, which isyou talked about the fact that
there have been somecross-sectional kind of designs,
but tell us about the studydesign that you use and the data
sources that you use to answerthese questions.
Adrienne Lee (05:39):
Sure.
So to address our researchquestions, we used data from the
Hispanic Community HealthSurvey/ Study of Latinos and
included participants whoidentified as current smokers at
the baseline visit.
We had two visits available forour study population in which
(05:59):
self-reported individual levelcigarette consumption data was
available.
Our primary exposure ofinterest was acculturation,
language acculturationspecifically, which was measured
using a short acculturationscale for Hispanics, and we used
primarily the language subscalebecause language explains most
(06:23):
of the variability inacculturation constructs and it
had the best psychometricproperties for our study sample.
We conducted analyses lookingat change in consumption
behaviors by comparing follow-upcigarette consumption behaviors
to baseline in linearregressions, and we also
(06:46):
measured quitting outcomes inlogistic regressions using those
individuals who were currentsmokers at baseline but who
endorsed no longer smoking attheir follow-up visit.
We further stratified ouranalyses and conducted subgroup
analyses by sex, educationalattainment and migration status,
(07:06):
and so we had about 2,000individuals in our final study
sample with two points ofcigarette consumption data
available, and we were able toreally look at those individual
level changes and theassociations between
acculturation and those smokingoutcomes.
Patrick Sullivan (07:25):
And about how far apart in time were the two
measures?
Adrienne Lee (07:30):
On average about seven years between the two
visits six and a half to sevenyears.
Patrick Sullivan (07:35):
It's quite a long interval to be able to get
the callback and, like, have ausable response rate.
So that's really interesting.
So so, now you have us allqueued up, what did you find?
What was the sort of keyfinding around this relationship
between acculturation andneither persistence or quitting
of smoking?
Adrienne Lee (07:51):
Sure.
So subgroup analyses were quiteinformative, and what we found
in our study is that among menwho were daily smokers, higher
levels of language acculturationwere associated with increased
cigarette consumption behaviors.
So over the course of thatseven-year period, on average
(08:13):
men increased by one cigaretteper day at those higher levels
of acculturation.
In our female sample we did notsee what we had been expecting.
We actually observed trendstowards declines in cigarette
consumption.
Additionally, when westratified our sample further by
(08:33):
educational attainment, we gotsome really interesting results
that weren't quite what we wereexpecting, and so we found that
among daily smokers, those whohad greater educational
attainment and higher levels oflanguage acculturation had a
much lower odds of quitting andtrended towards increased
(08:53):
cigarette consumption behaviors.
So our research does fill someimportant gaps in the literature
and provides some points foradditional research for us to
really delve into this further.
Patrick Sullivan (09:06):
Really interesting.
What do you make of thedifference between men and women
?
Sometimes we just say, like,that is what it is, and that
raises more questions Like doyou have any hypotheses based on
literature or other data?
Adrienne Lee (09:18):
So part of what could be explaining those sex
differences that we observed maybe the access and use of
healthcare services, whereasindividuals become more
acculturated as far as theirEnglish language use and their
(09:38):
ability to understand and intakeprevention or cessation
resources.
That might be consistent.
However, the sex differences ofwhether or not they're actually
accessing those resources anduptaking the services that are
being offered might be part ofthe explanation as to why we saw
these differences in ourfindings, compared to those
(10:01):
previous studies that looked atprevalence rates and sex
differences in prevalence rates.
Patrick Sullivan (10:07):
Yeah, you also had the difference between
previous studies that have doneprevalence based measures and
now you're doing somethingthat's longitudinal, and so I
think that study design alsodepending on what the sort of
patterns of use are, could alsogive you a different type of
data.
So that also might play in.
How did the data source measurecigarette consumption behaviors
(10:28):
?
Adrienne Lee (10:28):
So for daily and non-daily smokers, well,
everyone was asked whether ornot they had a history of
smoking and their lifetime and,if so, whether or not they were
current users.
And among those who werecurrent users, they were asked
whether they smoked daily ornon-daily.
And then, as far as consumption, they were asked specifically
(10:52):
how many cigarettes per day onaverage they consume as daily
smokers or as non-daily smokers.
Patrick Sullivan (11:00):
On the days that they do smoke, the average
number of cigarettes that areconsumed per day so I'm going to
just shout out to my Epi530class because we've been talking
about information bias andmisclassification.
So I just have to ask like doyou have any concern about
relying on self-reported data oncigarette consumption and sort
of what's known about potentialmisclassification?
Adrienne Lee (11:22):
Sure, and you know, self-reported measures
kind of inherently introduced.
These biases, and the ones thatwe're particularly concerned
with in this study, would besocial desirability bias and
that recall bias, you know,recalling over the past year the
average number of cigarettesthat were smoked.
I do believe that in thecurrent study those biases would
(11:48):
likely lead to under-reportingof consumed behaviors, where the
true consumption may likely behigher than what was actually
reported in the study.
And so in that sense, while thebias is there, I think we would
expect the results in theestimates to be still similar
(12:14):
changes, if not larger changesin the true data versus what was
reported in the study, and soin that sense we didn't do too
much to try to evaluate thatbias further.
But that is what we wouldanticipate in this context.
Patrick Sullivan (12:33):
Wonderful and uh- I am going to recommend this
to my Epi5 30 students becausethat's exactly the kind of
analysis we're working ondeveloping in class, so thank
you for that.
So, compared to what othershave found in terms of the
association of acculturation andchange in cigarette consumption
behavior, particularly amongHispanic/ Latino individuals,
(12:53):
how does what you found compareand why do you think it's the
same or different, or strongeror weaker?
Adrienne Lee (12:59):
Great question and so, as I mentioned, a lot of
what we found was differentfrom what has been published so
far in studying theseassociations, and so, where we
may have been expecting to findstronger associations in the
women that were included in ourstudy, what we found is that men
(13:21):
in fact had these associationsof higher acculturation level,
leading to increased consumptionbehaviors, and so, as we kind
of started to mention before,we're looking at individual
changes and there's a lot ofother factors that are going
into changing behaviors, asopposed to how someone is
(13:43):
behaving at any one given pointin time.
And within the scope of what wewere able to do in this study,
being one of the first studiesto really look at this
association, we had to keep itwithin the scope of our research
questions.
But some things to definitelyconsider, especially with our
findings of sex differences, are, you know, those access to
(14:07):
health care services orprevention services, and whether
or not those are actually beinguptaken by men or women and
what those drivers are in thoserelationships.
I think another thing that wefound that was different from
the literature and what we wereexpecting to see is that higher
educational attainment withhigher acculturation level was
(14:31):
associated with lower odds ofquitting, and I think that we
expect that with greateracculturation level, you may
have increased access toinformation and resources and
people who are facilitatinghealthier behaviors, and that's
not exactly what we see here.
(14:52):
We're seeing that this highereducation is either leading to
persistent or increased smokingbehaviors, and so really being
able to further study why thatwas the case and what is driving
that association I think isgoing to be an important next
step in the research focused onthe role of acculturation on
(15:15):
smoking behaviors for ourpopulation.
Patrick Sullivan (15:18):
Wonderful.
Well, we're going to turn nowfrom your research to understand
a little bit about how it cameabout, and this is we call
Behind the Paper, to try andunderstand a little bit more
about the process and whereeverybody doing this kind of
research were all people and sothose sort of humanistic aspects
of what we do.
So I'm just going to open up alittle discussion here.
(15:39):
First, respect for producingthis kind of really detailed
analysis and getting itpublished during your PhD
candidacy.
It's amazing work.
I wonder what was mostchallenging or maybe, if
anything, was frustrating aboutconducting this particular
research study.
So what was engaging andenjoyable?
What was more frustrating foryou?
Adrienne Lee (16:01):
Great question, and so I have to say that the
most challenging part of thisproject was also the most
engaging and enjoyable aspect ofit, which is that this study
cohort the study SOL (16:16):
Study of Latinos has a very robust
publication committee, and theyassigned subject matter experts
as co-authors to collaborate onthese papers, and they also have
an extensive review andapproval process for
(16:37):
publications using their data.
And so the challenge there being, as a PhD student at UC San
Diego and San Diego StateUniversity, the competing
priorities that we have whilemanaging a manuscript with so
many co-authors and managing theexpectations and the timelines
(17:00):
of the committee within areasonable time frame and
ensuring that we're enlistingall of the feedback and
expertise from those co-authorsin developing this paper.
I do think that ultimately, thatwas also a rewarding experience
to get exposure, of managingand leading a project that has
(17:20):
multiple stakeholders andco-authors involved in it, and
ultimately it resulted in a muchhigher quality and
well-informed publication, andso that engagement and
collaboration was definitelyenjoyable in the end, and I will
say also that, when you keep inmind, the bigger picture of
(17:43):
this publication committee andwhy they're doing their due
diligence to ensurecollaboration and to ensure high
quality, results are beingdisseminated from this study
ultimately comes back to thecommunity and ensuring that the
results that are beingdisseminated from this study are
(18:04):
having a positive impact andare not doing harm to the
individuals that we're aiming toserve, and that we're not
unintentionally eitherperpetuating stereotypes or
introducing stigma for thispopulation that we're ultimately
trying to serve.
And so, while it waschallenging at times, I think it
(18:27):
was also very much the mostengaging and enjoyable aspect of
the process.
Patrick Sullivan (18:33):
That's Patrick Sullivan
heard of that mechanism wherethere's this intentional
involvement of people in theresearch, in the dissemination,
in such a structured way.
So it's just really exciting tohear about that.
I mean, I wonder in thatrespect, like both the
perspective of participants butalso like academic partners,
(18:53):
researchers why is it importantto have that inclusion and
representation of the communityand Hispanic/L atino targeted
research or practice andprogramming?
How does that affect what comesout of the utility of it?
Adrienne Lee (19:08):
Sure, and so I'll start by saying I may have
buried the lead here.
I am Hispanic/ Latina myself.
I'm a first generation Dominicanborn in the US, and so, on a
personal level, professionally,this was truly one of the first
experiences that I've had wherethe majority of my collaborators
(19:30):
were Hispanic/ Latino, and thatdoesn't just include my
co-authors but the, you know,the people that were on the
special interest working groupsand in the publication committee
.
And so, from a personal level, Ithink just seeing that level of
representation and anaffirmation that there are
(19:52):
spaces at the table not just forHispanic/ Latinos but for
Latinas in particular, and thatour perspectives and our
contributions are important andvalued, I think is really
important to see at that levelfor myself and just as I
continue to aspire in my futurecareer goals.
(20:15):
But then, from a public healthperspective, you know it's
integral to health equity toinvolve the people from the
community in all of the phasesof research, from
conceptualization through todissemination, to ensure not
only that the interests of thepopulation are being considered
(20:36):
and incorporated, but that theircultural norms and perceptions
and those types of nuances arebeing incorporated into the
research.
That's being done with theultimate goal of having
effective interventions thatmake the intended impact for the
most vulnerable people in ourcommunities.
(20:57):
So critically important to havethat level of representation
throughout the process and inresearch in general.
Patrick Sullivan (21:05):
Thank you for that.
I'm going to ask kind of arelated question just about your
own journey to public healthand you're now in a place of
health equity research, which Ithink is a new recognition and a
critical recognition of abranch of these kinds of studies
.
How did your own backgroundshape your professional goals
and your interest in these areas?
Adrienne Lee (21:26):
So I will say that my early on in my career
trajectory I was interested inattending medical school, and so
a lot of my experience aftergraduating from college was in a
clinical setting, and I thinkmy interest really pivoted from
(21:47):
individual level care to more ofthis population level care when
I was working as a clinicaltrials research coordinator at a
cancer center, and in this roleI was very closely working with
and involved in the care andtreatment of all of the study
participants that we wereenrolling in my trials.
(22:09):
And so two things really startedto stick out to me, which is
that one the vast majority ofthe participants we enrolled in
our trials were white, nonHispanic and socioeconomically
from middle and upper classes,and the very few and far between
(22:31):
black and Hispanic participantsthat we did enroll I found
struggled with study adherenceand often had not as favorable
of health outcomes as some ofthe other participants.
So this really started to bloommy curiosity and I asked them
(22:52):
you know what are the reasonsthat we're not seeing you on?
You know your scheduled studyvisit days and nine times out of
10.
Very much socioeconomic factors, things like transportation or
unable to get off of work, oryour health insurance wasn't
(23:12):
covering the services for thestudy, and so I really saw this
spectrum of participants whowere either able to fly into the
city weekly for a 30 minutefollow up visit.
To the other end, you know,people who had to coordinate
(23:33):
transportation through theirchurch services and plan it a
month in advance, and so thesekinds of inequities just became
very apparent to me and led meinto more of a public health
space and to wanting to havemore of a population based
impact for those individuals whowere struggling the most in our
(23:56):
society, to try and get them tohave equitable outcomes when
we're trying to treat or preventany of the various health
outcomes that we're interestedin.
Patrick Sullivan (24:07):
Yeah, you raise such important points and
I think we see the same thing inAtlanta with research
participants and it's a part ofit is reflecting this sort of
underlying inequities, but froma research perspective, it's
also that exactly the samethings which is the reason that
some people don't come isbecause of transportation issues
(24:30):
are needing to work and thesort of socio economically
driven factors.
So two things.
That one is just the dignityand the respect of trying to
make sure that each person getswhat they need to be able to
meaningfully participate.
So for us that means some folksneed Uber rides to get to the
clinic visit and some folksdon't, and so we provide that
(24:50):
and we moved our research clinicto be like a block away from a
Marta station, which is oururban train, in a subway system
to try and minimize thosebarriers.
So it's both about equity andrespect for individuals, but
it's also about the inclusion ofdiverse participants.
So there is also, from an epipoint of view, a selection bias
(25:11):
or retention bias that I thinkis really important In this case
, like thinking a next layerdown about how we, the equity
lens of saying how do we make itequally easy for everyone to
participate, which doesn't meaneverybody needs to get the same
thing, but it means that we'retailoring how we support people
participating in research tomeet their needs.
It's both equitable and right,but it's also better for
(25:32):
research and that we don't havesome of those selection biases
or retention biases, you know,if we take a one size fits all
approach to how we supportpeople in research, so it's
interesting and analogous in adifferent population here.
So last is someone who is inyour PhD program.
I want to do two things.
One is you're going to bemoving towards finishing and
(25:53):
where do you want to head nextfor all of the folks who listen
to, who may be have postdocpositions and junior faculty
positions like where do you wantto head and what's the next
step for you when you're done?
Adrienne Lee (26:04):
Thank you for that question, and so I will
have a plug that the NationalInstitute on Aging Award that
I've received this year tofinish my dissertation work as
well as transition me into apostdoctoral position, is really
one that is presenting me witha tremendous opportunity.
(26:25):
I think the next phase in myprofessional development will be
one to get additional trainingin additional social
epidemiology, but alsospecifically in implementation
science and really trying tokind of understand how, in with
these evidence based practices,can we effectively translate
(26:50):
these interventions intopopulations that we know are at
great risk for certain agingoutcomes, and so getting that
type of exposure and experiencesprimarily what I am looking for
in this next phase.
I have a few institutions thatare at the top of my list, but
(27:11):
you can't reveal, all will be.
Yeah, yeah, we'll go through theappropriate processes and
ensuring that, you know, we endup in a place that has the
resources to really continue tosupport my ultimate research
goals.
Patrick Sullivan (27:27):
One last question.
You're in a doctoral program.
You've survived, you've thrived, you've gotten this cool pre to
post doctoral transition grant.
What piece of advice would youhave for students are coming
into their doctoral program,based on what your experience
has been?
Adrienne Lee (27:43):
So my advice to incoming students would be to
regularly reflect and update youknow an individual development
plan and to really be sure thatthey have goals in mind for the
types of training or experiencesthat they want to gain during
(28:05):
this program, and seeking outthose opportunities, or creating
those opportunities, so thatyou can ensure that you're
getting what you want out ofthis program.
As I mentioned, there's a lotof competing priorities when
you're in a PhD program.
It's not just the coursework orthe qualifying exams you know,
(28:25):
your paid research, but also theside projects that you
participate in, and so managingyour priorities and ensuring
that you are getting what youwant to get out of this
opportunity with the time thatyou have.
Patrick Sullivan (28:41):
But great advice and thank you for sharing
that.
So do you have any finalthoughts that you'd like to
share with our listeners?
Adrienne Lee (28:49):
Just that- as public health professionals, we
have, hopefully, a shared goaland interest to improve the
health and well being ofeveryone that lives within our
society, and not just toincrease the lifespan but really
increase the health span ofindividuals living within our
(29:11):
communities, and so ensuringthat we're taking this health
equity approach and being ableto identify those in our
communities who need the mosthelp to really be able to live
happy and healthy long liveswould be my public service
announcement for the listenerstoday.
Patrick Sullivan (29:33):
And what a great way to wrap up our episode
.
Thank you again so much forjoining us today.
It was really a pleasure tohave you and we'll hope to see
much more of your work at Annalsof Epidemiology and the other
places that you publish it inthe future.
Congratulations.
Adrienne Lee (29:48):
Thank you so much for having me today.
Patrick Sullivan (29:50):
I'm your host, Patrick Sullivan.
Thanks for tuning in to thisepisode and see you next time on
EPITalk, brought to you byAnnals of Epidemiology, the
official journal of the AmericanCollege of Epidemiology.
For a transcript of thispodcast or to read the article
featured in this episode andmore from the journal, you can
visit us online at www.
(30:12):
annalsofepidemiology.
org.
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