This guide is intended to be used by health practitioners, researchers, and statisticians who are interested in collecting data on
tobacco use, cessation, secondhand smoke, risk perceptions and social influences, and demographic information from Hispanic/Latino
populations. Specific sections of the guide may be most appropriate for specific uses: health practitioners might use Sections A, B,
and F; interviewer training may benefit most from Section B; and researchers and statisticians may want to consult Sections C, D, and
E. In this section we provide this array of users with the detailed history, theoretical demands, and practical considerations informing
the Hispanic/Latino Adult Tobacco Survey (H/L ATS). We conclude with a bibliographic list of resources subdivided by content area of the
guide. Contact information completes the resources offered here.
F.1 Background to the Development of the H/L ATS
The H/L ATS is a culturally appropriate adult tobacco use questionnaire administered to determine among Hispanic and Latino adults in the
United States the prevalence of tobacco use, exposure to secondhand smoke, and exposure to influences for and against tobacco use. The
availability of a consistent, well-developed questionnaire will improve the quality of this information, which will in turn aid in the
development of culturally sensitive and effective tobacco control programs for Hispanic and Latino populations. Section F.1 provides the
user of this guide with the background and rationale for the development of these survey materials.
F.1.1 Purpose of a Culturally Appropriate H/L ATS
Hispanic and Latino persons residing in the United States embody a unique set of attitudes, behaviors, knowledge, experience, and other
cultural characteristics. These characteristics call for a customized approach to measuring health-compromising behaviors such as tobacco
use, in order that truly effective cessation and prevention programs may be developed in this population at the local, state, and regional
levels (Kerner, Breen, Tefft, & Silsby, 1998). To this end, in 2002, under the direction of the Centers for Disease Control and Prevention
(CDC), Office on Smoking and Health (OSH), the General Population State ATS was adapted to create the H/L ATS. The H/L ATS was designed
specifically to measure general health, tobacco use, cessation, exposure to secondhand smoke, risk perceptions, social influences, and
demographics among Hispanic and Latino adults.
For information and background on the General Population State ATS, see the Guidelines for Conducting General Population State Adult
Tobacco Surveys (Mariolis, in press).
Growth in Hispanic and Latino Populations
The need for targeted, culturally sensitive tobacco use prevention programs is substantiated by the growing number of Hispanic and Latino
persons residing in the United States. The
U.S. Hispanic and Latino population already constitutes a large portion of the overall population, and the numbers are increasing rapidly.
According to the U.S. Census Bureau, in 2003 there were 39.9 million Hispanic/Latino persons living in the United States (U.S. Census
Bureau, 2004), a 78% increase over 1990 (22.4 million). It is expected that the number of Hispanic/Latino persons living in the United
States will increase to 102.6 million by the year 2050. If these Census projections are correct, 24.4%, or about 1 of every 4 persons
residing in the United States, will be of Hispanic or Latino origin (U.S. Census Bureau, 2004).
If the Hispanic/Latino adult smoking prevalence remains at its average level of 18.3% (1990–1999) for the next 50 years, the number of
Hispanic and Latino adult smokers will increase from 3.8 million in the year 2000 to 11.0 million in the year 2050. Although the H/L ATS
is not administered to those under the age of 18, data on adults will inform prevention programs for younger Hispanic and Latino persons,
who are the largest minority youth population in the United States and 16% of the population under age 18 (Flores et al., 2002).
Tobacco Use and Exposure Among Hispanic and Latino Populations
The Hispanic and Latino populations in the United States face unique challenges that put them at higher risk than the general population
for tobacco use and exposure to smoke:
Depending on location, about one fifth of Hispanic or Latino persons have low English-language skills (U.S. Census Bureau, 2004).
The Hispanic and Latino populations are likely to have limited exposure to anti-tobacco use information, educational materials, media
messages, and cessation services, compared with those who have better English-language skills.
The Hispanic and Latino populations continue to be the target of intensive tobacco-industry marketing efforts. These efforts include
sponsorship of cultural events, funding of Hispanic and Latino organizations and issues, and other targeted marketing efforts.
Initial evidence suggests that Hispanic and Latino workers tend to be more exposed than other workers to secondhand smoke on the job.
This increased exposure occurs even though Hispanic and Latino populations often demonstrate high levels of awareness of the health
risks posed by secondhand smoke, as well as strong support for smoke-free policies.
As Hispanic and Latino persons become more acculturated, initial findings suggest that their rate of smoking is increasing and approaching
that of the general population. This trend is of particular concern with regard to younger people.
Several issues pertain directly to the design and implementation of successful tobacco control programs in the Hispanic and Latino population
assessed with the H/L ATS:
Prevalence of "occasional," or nondaily, smoking.
Increase in use of menthol cigarettes.
Prevalence of smoking cessation and quit attempts.
Methods used to quit, including nontraditional methods possibly unique to
Hispanic/Latino persons.
Rules and perceptions about secondhand smoke exposure in the home and at work.
Additional demographic considerations (e.g., country of birth, education and income levels, length of stay in the United States).
Hispanic and Latino communities have unique strengths and assets conducive to effective tobacco control initiatives. By acting now to help
these communities implement sustained, culturally appropriate tobacco control interventions, researchers and health practitioners can avert
the predicted rise in smoking and the associated danger of smoking-related disease.
F.1.2 Design of the H/L ATS Questionnaires and Survey Methodology
CDC convened a meeting of leading researchers and health program administrators, "Effective Tobacco Control in Hispanic/Latino Communities,"
in August 2002. The purpose of this meeting was to address questions about tobacco control specifically as it relates to program, policy,
communication, surveillance, and evaluation in various Hispanic and Latino populations. The subsequent findings and recommendations specific
to surveillance needs assisted in the development of the H/L ATS. Recommendations that directly influenced the development of the H/L ATS
included the following:
Increase sample sizes to generate more precise estimates of tobacco use prevalence in Hispanic and Latino populations.
Collect information on secondhand smoke exposure rates and on attitudes toward
public policy.
Appropriately adapt, both culturally and linguistically, survey questions for the
Hispanic/Latino population.
Monitor the prevalence of and trends in "occasional smoking" among Hispanic and
Latino populations.
Collect data at the regional and state levels.
Track and analyze the effects of acculturation, income levels, and education levels on tobacco use prevalence and behaviors among
Hispanic and Latino populations.
Conduct research on whether differences in tobacco use prevalence between specific Hispanic/Latino populations are due to differences
in culture or to differences in class and income (or socioeconomic) status.
Examine the reasons for disparities among various Hispanic/Latino populations.
During the meeting, strong consensus emerged that tobacco control interventions that acknowledge and highlight the cultural strengths,
assets, and protective factors of the Hispanic and Latino population would be most effective. Conversely, it was agreed that interventions
that failed to recognize the unique linguistic, social, and cultural characteristics of this population would be relatively ineffective.
Questionnaire Design
During the August 2002 meeting, 10 researchers reviewed the OSH General Population State Adult Tobacco Telephone Survey. These 10
researchers were selected for the review of the survey instrument because of their expertise in tobacco control and their research
experience with specific Hispanic and Latino subpopulations (e.g., Mexican American, Puerto Rican, and Cuban). The researchers advised
OSH which questions were appropriate and which were inappropriate for Hispanic and Latino populations.
Five of the original 10 researchers were subsequently identified to provide more in-depth recommendations on how to adapt the survey for
the Hispanic and Latino population. A second meeting was held at CDC, where the five researchers and an OSH epidemiologist continued to
modify the General Population State ATS to make the questions more culturally appropriate for Hispanic and Latino subgroups. In addition,
new questions specific to Hispanic and Latino populations were added to the instrument, such as the following: "In the past 12 months,
have you seen a medicine man (curandero), santero, spiritist (espiritista), herbalist (yerbero), religious leaders (priest, pastor, rabbi,
etc.), or other non– health professionals to help you quit smoking?" New demographic questions also elicit country of birth, educational
levels, income levels, and language preference.
Survey Methodology
The H/L ATS is meant to be readily usable by public health organizations at all levels. The H/L ATS can be administered either as a
telephone interview or as an in-person interview, and in English or Spanish.7 Two of the case studies described in Section C use telephone
administration, and the third uses in-person interviewing. Each of the case studies selected the administration mode that best suited its
particular study population. To further increase the usability of the H/L ATS, complementary survey materials (i.e., screeners, consent
forms, and advance letters in both English and Spanish) were developed as part of the H/L ATS package.8 All materials are publicly available
to jurisdictions, organizations, and individuals.
7The H/L ATS questionnaire and screener are available in three versions: all English, all Spanish, and Spanish with English instructions
for interviewers and programmers. The designers of the H/L ATS have anticipated that the survey may be used in countries where Spanish is
the national language. The "all Spanish" version is appropriate when all interviewers, programmers, and survey staff are Spanish monolinguals.
The "Spanish with English instructions" version is appropriate when it is expected that those programming the computerized version of the
questionnaire will be English monolinquals.
8The consent form and consent text provided here differ slightly from those used in CDC's 2007 survey.
F.1.3 Development of Spanish Versions of the H/L ATS
Consensus Approach to Translation
Committee approaches to translation have been used since the 1960s (Nida, 1964) and more recently in the translation of data collection
instruments (Acquadro, Jambon, Ellis, &
Marquis, 1996; Brislin, 1976; Guillemin, Bombardier, & Beaton, 1993; Schoua-Glusberg, 1992). Moreover, the Census Bureau guideline for survey
translation now recommends this approach (U.S. Census Bureau, 2004). Its strength is that consensus among bilinguals produces more accurate
text than the subjective opinion of a single translator: problems of personal idiosyncrasies, culture, and uneven skill in either language
are overcome. Translation by committee produced the Spanish version of the H/L ATS.
The core modules of the H/L ATS were originally translated into Spanish by an epidemiologist within OSH. This translation underwent review
by a team of three translators who are native speakers of some of the main varieties of Spanish spoken in the United States (Mexican, Puerto
Rican, and South American). This review was refereed by a specialist with 2 decades of experience in chairing survey translation committees.
For the supplemental modules, there existed no original Spanish translation. The team of three translators worked independently, translating
from English one third of the protocol each. After this initial translation, another refereed reconciliation meeting was held to ensure each
item reflected the intent of the English original and was equally effective in Spanish.
In reconciliation meetings, each translator contributed to the discussion to improve and refine the translation, in order to make the Spanish
culturally appropriate for the three majority Latino or Hispanic populations. In the discussions, each member was required to articulate the
reasons for suggested changes or improvements to the original translation. The team looked together for alternative translations, finally
selecting by consensus.
Cognitive Research to Enhance Cultural Adaptation
Upon completion of the translations, the questionnaires were subjected to extensive cognitive testing with members of the target populations
residing in Miami, New York City, El Paso, and Chicago. Cognitive testing was conducted to establish that the questions are culturally appropriate
and sensible; that they will be understood similarly across participants of different national origins, education levels, or income levels; and
that the Spanish translation works well across such a diversity of respondents. As is the case in every cognitive evaluation project, a goal was
also to identify any question-processing problems or difficulties respondents might experience—including cognitive complexity of questions, words
not understood, problems in stems or response categories, and recall issues—that could lead to measurement error.
Cognitive interviews are a qualitative method that determines not only which items work and which present problems, but also why certain items do
not work. Because they are bilingual, translators are systematically different from the monolingual (and often monocultural) population for whom
the translated instrument is prepared. With the use of such qualitative methods, the generation of a translated text brings together, at each
stage of the process, the combined efforts of professional translators and the input of the audience.
Sixty-eight interviews—19 in English, and 49 in Spanish—were conducted in two rounds, between June 2004 and April 2005 (Table F-1). Recruiting
for interviews was accomplished through community organizations and agencies in each city.
Table F-1. National Origin, City of Residence, and Language of Interview for Respondents to the H/L ATS Cognitive Testing
Origin and residence
Spanish interviews
English interviews
Mexico
Chicago
2
0
El Paso
12
0
Puerto Rico
Chicago
3
1
New York
5
3
Cuba
Chicago
1
0
Miami
5
5
El Salvador
Chicago
3
0
Columbia
Chicago
4
0
Dominican Republic
Chicago
2
0
New York
5
5
Guatemala
Chicago
4
1
Ecuador
Chicago
0
2
Honduras
Chicago
1
2
Peru
Chicago
2
0
Findings from the first round of interviews were used to make changes intended to reduce or eliminate problems and error. In the second
round, these changes were tested. The current, final version of the English and Spanish H/L ATS includes the modifications stemming from
both rounds of cognitive interviews. The resulting version is suitable for the broader Latino population of the United States.
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