Perceptions of Personal Risk About Smoking and Health Among ...

J Immigrant Minority Health DOI 10.1007/s10903-011-9511-4

ORIGINAL PAPER

Perceptions of Personal Risk About Smoking and Health Among Bosnian Refugees Living in The United States Jenine K. Harris • Ajlina Karamehic-Muratovic Stephanie H. Herbers • Sarah Moreland-Russell Robin Cheskin • Kari A. Lindberg

• •

Ó Springer Science+Business Media, LLC 2011

Abstract More than 60% of Bosnian refugees in the United States may be current smokers. Examining health beliefs can provide insight into smoking behaviors in this community. Four hundred ninety-nine Bosnians were interviewed about health beliefs and personal health risks related to smoking. ANOVA was used to compare current, former, and never smokers. General health beliefs were significantly different by smoking status with medium effect sizes (P \ .001; g2 = 0.04–0.06); current smokers were less likely to agree that smokers live shorter lives and that smokers are more likely to get heart disease. Significant differences with large effect sizes (P \ .001; g2 = 0.11–0.29) were found in perception of personal risk of lung cancer and heart disease among current, former, and never smokers. Current smokers perceived their own health risks as less severe than those of other smokers. High smoking rates and smokers’ optimism related to health indicate that culturally tailored educational and cessation interventions are needed for Bosnian refugee communities. Keywords Bosnian refugees Smoking Health risk perception

J. K. Harris (&) S. H. Herbers S. Moreland-Russell R. Cheskin K. A. Lindberg George Warren Brown School of Social Work, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO 63130, USA e-mail: jharris@brownschool.wustl.edu A. Karamehic-Muratovic Department of Sociology and Criminal Justice, Saint Louis University, St. Louis, MO, USA

Introduction The harmful health effects of smoking are staggering. Cigarette smokers are two to four times more likely to develop coronary heart disease [1–8] than non-smokers, and smoking doubles a person’s risk for stroke [9–12]. Tobacco smoke significantly increases the risk for lung, mouth, throat, stomach, bladder, and colon cancers [1]. Because of these harmful health effects, one in two lifetime smokers will die from their habit [13]. Despite the health risks related to smoking, people continue to smoke. Theories such as the Health Belief Model [14] and the Theory of Reasoned Action [15] aid in explaining and predicting health behaviors. For example, the Health Belief Model suggests that individuals will take action to change behavior if they regard themselves as susceptible to outcomes of that behavior (e.g., lung cancer due to smoking), if the behavior has serious consequences (e.g., death), if they believe a specific course of action will reduce their susceptibility or seriousness of the consequences, and if the costs of taking action outweigh the benefits [16]. When exploring how health beliefs influence smoking behavior, research shows that smokers may recognize they have increased risk for certain diseases; however, they tend to underestimate the risk, not recognizing its severity and consequences [17]. Based on models such as the Health Belief Model, the underestimation of risk can be a significant barrier to taking action to quit smoking. Smoking Among Bosnian Refugees Bosnian refugees are three times more likely to smoke (64%) compared to the US national average (20.6%) [18]. Higher smoking rates are not unique to Bosnian refugees.

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Studies of adult refugees including those from Bosnia, Cuba, Iran, Iraq, Kosovo, Vietnam, and other countries found an overall smoking rate of 38.5%. However, Bosnian refugees had significantly higher smoking rates (51.3%) than other refugee groups (P \ 0.05) [19]. Smoking prevalence among Bosnian refugees also tends to be higher than smoking among current residents of Bosnia and Herzegovina. According to the most recent World Bank data available, 2006 smoking prevalence estimates for those living in Bosnia and Herzegovina were 48% for males and 35% for females (http://data.worldbank.org/indicator/). Previous research suggests that Bosnian refugees living in the United States who smoke estimate their risk for lung cancer and heart attack as lower than the risk of other smokers, and about the same as the risk of non-smokers [20]. For regions with high concentrations of Bosnian refugees, the high smoking rate and inaccurate beliefs about smoking and health are of particular importance due to the potential burden of smoking-related disease in these communities. St. Louis, Missouri is home to an estimated 50,000 Bosnian refugees who resettled in the area following the 1992–1995 war in Bosnia and Herzegovina. Unlike voluntary immigrants, a refugee is an individual who, ‘‘owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country’’ [21]. During the Bosnian refugee resettlement time period, St. Louis became one of ten preferred locations [22]. Since then, the St. Louis Bosnian community has undergone growth resulting from primary resettlement, secondary resettlement, and family reunification programs. Bosnian refugees living in St. Louis comprise about 16% of the city’s population; recent estimates indicate the population may be even larger due to secondary migration and underreporting [23]. Understanding health beliefs and related health behaviors among Bosnian St. Louisans is an important step in selecting and implementing effective interventions to reduce smoking rates in this and other Bosnian refugee communities. Building on prior evidence of health beliefs in Bosnian refugees [20] and the central tenets of the Health Belief Model [14, 16], we sought to examine smoking behavior and beliefs about smoking and health in Bosnian refugees in St. Louis by exploring two research questions: RQ1: What are the beliefs of St. Louis Bosnian refugees with regards to smoking and health? RQ2: How do St. Louis Bosnian refugees perceive their own smoking-related health risks?

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Methods Participants A convenience sample of 499 Bosnian refugees was recruited from the St. Louis area. Multiple sources and venues were utilized for recruitment, including prayer times at two mosques, Bosnian community events, societies and groups, ads in the local Bosnian newspaper, and contacts of a local nonprofit. The sample was 47.8% (n = 239) male, with a median age of 44 years (range: 18–88). Seventy-nine percent had at least one child and 69.8% were married. Fifty percent had completed high school and 8.0% had a college degree. On average, participants had lived in the United States 9.8 years (SD = 2.4), and 94.6% (n = 473) identified themselves as Bosnian. There were few Serbians (1.2%; n = 6) or Croations (3.8%; n = 19) in the sample due to strategic placement strategies for different refugee groups through the federal ‘preferred communities’ program [24, 25]. Almost two-thirds identified themselves as current smokers (66.4%), 20.2% as non-smokers, and 13.0% as former smokers. Of current smokers, 77.6% smoked 20 or fewer cigarettes per day (up to one pack), 20% smoked one to two packs, and 2.4% smoked more than two packs per day. Table 1 shows demographic characteristics by smoking status. Questionnaire Development and Administration A questionnaire about smoking and health was developed in English using demographic and smoking behavior items adopted from the Behavioral Risk Factor Surveillance Survey (BRFSS) [24] and risk perception items adopted from the Smoking in Your Community survey [20]. The questionnaire was translated into the Bosnian language and back-translated into English by fluent speakers. Original and back-translated versions of the questionnaire were compared and minor adjustments were made to ensure consistent meaning. Questionnaires were administered verbally in Bosnian by trained and paid Bosnian community members. Questionnaire completion took an average of 49.5 min (SD = 12.8). Participants received $25 grocery gift cards. Data were entered twice and compared; data entry errors identified were corrected. Measures Demographics, Smoking, and Cessation Demographic questions included age, gender, education, marital status, and parental status. Smoking behavior questions included, ‘‘Do you currently smoke cigarettes every day, some days, or not at all?’’ Those who answered

J Immigrant Minority Health Table 1 Sample characteristics and smoking status for Bosnian refugees living in St. Louis, Missouri 2007–2008 (N = 499) Never smoker (N = 101) N (%)

Former smoker (N = 65) N (%)

Current smoker (N = 332) N (%)

Age (median, range)

44 (18–88)

53.9 (17.4)

41.9 (13.4)

Age of smoking initiation (m, SD)

n.a.

19.8 (6.7)

20.1 (6.6)

Years living in the US (m, SD)

9.6 (2.6)

10.1 (2.2)

9.8 (2.4)

Male

37 (37)

36 (55)

165 (50)

Female

64 (63)

29 (45)

166 (50)

63 (63)

46 (71)

239 (72)

1 (1)

4 (6)

2 (1) 20 (6)

Gender

Marital status Married Separated Divorced

3 (3)

2 (3)

Widowed

19 (19)

12 (19)

24 (7)

Never married

14 (14)

1 (2)

46 (14)

14 (14)

8 (12)

17 (5)

Education No school Some grade school

8 (8)

4 (6)

6 (2)

Grade school

13 (13)

5 (8)

44 (13)

Some high school High school

2 (2) 39 (39)

3 (5) 29 (45)

2 (1) 181 (55)

Vocational

11 (11)

12 (19)

34 (10)

Some college

6 (6)

1 (2)

20 (6)

College

8 (8)

3 (5)

28 (8)

Yes

79 (78)

59 (91)

256 (77)

No

22 (22)

6 (9)

75 (21)

Children

Smoking intensity (current smokers only) 1–10 cigarettes per day

123 (37)

11–20 cigarettes per day

134 (41)


42 (13)


24 (7)


5 (2)


2 (1)

61? cigarettes per day

1 (0)

‘‘not at all’’ were then asked, ‘‘Are you an ex-smoker (you used to smoke but quit)?’’ Results from these two questions were used to develop the three category smoking status variable (current smoker, former smoker, never smoker). Smoking intensity was measured with an ordinal scale representing the number of cigarettes smoked per day in half-pack increments. Willingness to quit smoking was measured on a five-point Likert scale ranging from one (Strongly disagree) to five (Strongly agree) with the following statement, ‘‘I really want to stop smoking.’’ Current smokers were also asked, ‘‘During the past 12 months,

have you stopped smoking for 1 day or longer because you were trying to quit smoking?’’ Those who answered yes were asked what cessation aids they used, if any. Former smokers were also asked what cessation aids were used, if any, when they quit. Health Risk Perception Measures First, participants indicated their agreement with three statements on a five-point scale. Risk items included, ‘‘Smokers live shorter lives than non-smokers,’’ ‘‘Smoking increases your chance of getting lung cancer,’’ ‘‘Smokers are more likely to get heart disease.’’ Second, participants were asked to compare their own risk for lung cancer and heart disease to the risk of smokers and non-smokers their own age. A five-point scale was used, with one being ‘‘Not at all likely’’ and five being ‘‘Very likely’’. Analysis One-way analysis of variance (ANOVA) was used to examine differences in the three general risk items by smoking status. Repeated-measures ANOVA was used to compare participants’ perception of their own likelihood of heart disease and lung cancer to their perception of the likelihood for smokers and non-smokers their own age. Group means and standard deviations reported were calculated as part of the ANOVA procedure. Spearman correlations were used to examine the association between smoking intensity and risk perceptions among current smokers. Where significant ANOVA results were found we calculated the strength of association and identified groups significantly different from one another. Strength of association was determined using eta-squared (g2), an effect size indicating how much of the dependent variable is explained by the independent variable. Eta-squared is categorized as small (g2 = 0.01), medium (g2 = 0.06), or large (g2 = 0.14) by Cohen [26]. Groups significantly different from one another were identified through Tukey’s Honestly Significant Difference (HSD) test for the one-way ANOVA and pairwise comparisons using a Bonferroni adjustment for repeated-measures ANOVA. In reporting repeated-measures ANOVA results, the Greenhouse-Geisser adjustment to the F test-statistic was made when the sphericity assumption was not met; this was indicated by the subscript ‘‘GG’’ when used. PASW version 18.0 [27] was used for analyses.

Results RQ1: What are the beliefs of St. Louis Bosnian refugees in regards to smoking and health? The average level of

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J Immigrant Minority Health Table 2 Health beliefs and smoking status among 499 Bosnian refugees living in St. Louis, Missouri (2007–2008)

Smokers live shorter lives than non-smokers (n = 498)

Former smoker m (SD)

Current smoker m (SD)

F

3.94 (0.98)a

3.65 (1.23)b

3.26 (1.15)a,b

15.17 \0.001

0.06

9.27 \0.001

0.04

13.94 \0.001

0.05

a

Smoking increases your chance of getting lung cancer (n = 498)

4.21 (0.84)

Smokers are more likely to get heart disease (n = 497)

4.32 (0.81)a

a

4.06 (1.03)

3.76 (1.00)

4.15 (0.99)b

3.77 (1.03)a,b

P

g2

Never smoker m (SD)

Scores ranged from 1 to 5 with higher scores indicating stronger agreement with each statement a,b

Group means significantly different at P \ 0.05 by Tukey’s Honestly Significant Difference test

agreement with each of the three health belief statements ranged from 3.26 to 4.32 on a scale of 1 (Strongly disagree) to 5 (Strongly agree) (Table 2). There were significant differences in agreement (P \ 0.001) with medium effect sizes (g2 = 0.04–0.06) between smoking status for all three health beliefs, with smokers showing the lowest levels of agreement across all statements. Specifically, never smokers had a significantly higher average level of agreement than current smokers that smokers live shorter lives and are at higher risk for lung cancer and heart disease. Former smokers agreed more strongly than current smokers with the statements about shorter lives and heart disease, but were no different than current smokers in beliefs about lung cancer. There were no significant differences between never smokers and former smokers in agreement with the statements. RQ2: How do St. Louis Bosnian refugees perceive their own smoking-related health risks? We compared participants’ perceptions about their personal health risks pertaining to heart disease and lung cancer to their perceptions about the same health risks for smokers and non-smokers of their own age. Never Smokers A repeated-measures ANOVA found significant differences with a large effect size (FGG = 30.56; P \ 0.001; g2 = 0.24) in never smokers’ perceptions of their own likelihood of heart disease (m = 3.07; SD = 0.95), the likelihood of heart disease in never smokers (m = 3.13; SD = 0.91), and the likelihood of heart disease for smokers (m = 3.79; SD = 0.97). Pairwise comparisons indicated that never smokers found their own likelihood of heart disease and the likelihood for non-smokers each to be significantly less than that of smokers (P \ 0.001). Never smokers did not think their likelihood for heart disease was significantly different from non-smokers. Similar significant differences and a large effect size were identified for never smokers’ perceptions of their likelihood of lung cancer (F = 55.24; P \ 0.001; g2 = 0.24). Never smokers thought their own likelihood of lung cancer (m = 2.77; SD = 0.96) was significantly lower (P \ 0.001) than smokers (m = 3.86; SD = 1.03), but was not

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significantly different from non-smokers (m = 2.95; SD = 0.88). Never smokers also thought that non-smokers had a significantly lower likelihood of lung cancer than smokers (P \ 0.001). Overall, never smokers perceived their risk for heart disease and lung cancer as consistent with non-smokers, while they perceived smokers to have higher risk than themselves or non-smokers (Fig. 1a). Former Smokers Former smokers felt there were significant differences with large effect sizes in the likelihood of heart disease (F = 24.06; P \ 0.001; g2 = 0.27) and lung cancer (F = 25.91; P \ 0.001; g2 = 0.29) between themselves, non-smokers, and smokers. Pairwise comparisons showed that former smokers believed their own likelihood (m = 3.25; SD = 0.99) of heart disease was no different (P [ 0.05) from nonsmokers (m = 3.00; SD = 0.81), but was significantly (P \ 0.001) lower than smokers (m = 3.88; SD = 0.89). Similarly, former smokers identified their risk for lung cancer (m = 2.98; SD = 1.07) as no different (P [ 0.05) from the risk for non-smokers (m = 3.08; SD = 0.91) but significantly lower (P \ 0.001) than smokers (m = 3.92; SD = 0.85). In general, former smokers identify their risk for heart disease and lung cancer the same as that of nonsmokers and believe generally that smokers and non-smokers have different risk levels (Fig. 1b). Current Smokers Current smokers perceived significant differences with medium to large effect sizes in the likelihood of heart disease (FGG = 40.46; P \ 0.001; g2 = 0.11) and lung cancer (FGG = 47.39; P \ 0.001; g2 = 0.13) for themselves, non-smokers, and smokers. Specifically, current smokers perceived their own likelihood for heart disease (m = 3.30; SD = 0.88) as significantly higher (P \ 0.001) than the likelihood for non-smokers (m = 3.03; SD = 0.83) and significantly lower (P \ 0.01) than the likelihood for smokers (m = 3.45; SD = 0.89). Current smokers also indicated that non-smokers had a significantly lower risk than smokers (P \ 0.001). In addition to heart disease, current smokers felt their own risk for lung cancer


Likelihood of Disease

(a)

5 4

being more likely to perceive their risk as similar to nonsmokers), we examined the correlation between each risk perception item and smoking intensity among current smokers. All of the correlations were weak and non-significant, ranging from -0.09 to 0.08 with P values between 0.12 and 0.91. Smoking intensity does not appear to influence risk perception in this group.

Heart disease Lung cancer

3 2

Perceptions About Quitting

1

Self

Non-smoker

Smoker

Likelihood of Disease

(b) 5 4

Heart disease Lung cancer

3 2 1

Self

Non-smoker

Smoker

(c) Likeihood of Disease

5 4

Heart disease

Over half (57.4%) of the current smokers agreed that they, ‘‘really want to stop smoking.’’ The rest (42.3%) of current smokers in this community were ambivalent or disagreed with the statement. Of current smokers, 30.5% (n = 100) stopped smoking for 1 day or longer in the last year. Of these, 20 used any cessation aid including 15 who used gum, the patch, or other medication, three who used classes or counseling, and one who used one-on-one assistance from a doctor or nurse, and one who used another aid. Of the 65 former smokers interviewed, just six used cessation aids such as nicotine patches, gum, or medication (n = 4), classes or counseling (n = 1), or one-on-one assistance from a doctor or nurse (n = 1).

Lung cancer

Discussion

3 2 1

Self

Non-smoker

Smoker

Fig. 1 Perceptions of likelihood of heart disease and lung cancer for self, non-smokers, and smokers among never smokers, former smokers, and current smokers where 1 is Not at all likely and 5 is Very likely. a Never smokers’ perceptions of disease likelihood. b Former smokers’ perceptions of disease likelihood. c Current smokers’ perceptions of disease likelihood

(m = 3.14; SD = 0.94) was significantly higher (P \ 0.001) than the risk for non-smokers (m = 2.97; SD = 0.85) but significantly lower (P \ 0.01) than the risk for smokers (m = 3.45; SD = 0.89). They felt that smokers, however, had significantly higher risk for lung cancer than non-smokers. Generally, current smokers perceived their own health risks as less severe than smokers their own age. However, they also reported typical smokers as having higher risk than non-smokers for heart disease and lung cancer (Fig. 1c). Perceived Risk and Smoking Intensity To determine whether there was any relationship between smoking intensity and risk perception (e.g., lighter smokers

While one of the major strengths of this study is its large sample size, limitations include cross-sectional design and convenience sampling. Cross-sectional study designs provide a snapshot from a single point in time allowing for the identification of relationships among variables, but are limited in inferring causality. Furthermore, the participants were not randomly selected from the community, so the results are not necessarily generalizable. Additionally, participants were identified and interviews were conducted by community members, which likely increased the social desirability bias given the collectivistic nature of Bosnian communities [28]; it is likely that some participants knew their interviewers through personal channels [29]. Social desirability bias may lead to under-reporting of smoking and smoking intensity [30, 31]. The Health Belief Model outlines several key variables that influence an individual’s behavior: perceived susceptibility and severity, perceived benefits and barriers, other modifying factors such as demographics and culture, and specific cues to action. With regard to susceptibility and severity, understanding of the health effects of smoking is mixed among current smokers in the Bosnian refugee community. Current smokers were significantly less likely to agree that smokers lived shorter lives than non-smokers or that they were at increased risk for heart disease. In addition, while smokers seemed to have some understanding of the

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increased likelihood of heart disease and lung cancer when compared to non-smokers, they did not necessarily perceive these increases as personally applicable. Also, when it came to heart disease and lung cancer, former smokers believed their health to be about the same as those of non-smokers. This demonstrates a potential self-exempting or cognitive dissonance related to personal health risk and a lack of recognition of the serious and lasting health effects related to smoking among smokers and former smokers in this community. Some of our findings are not unique to the Bosnian community [17, 32–34]. The difference between former smoker and smoker perceptions of health risk has been well documented [34], and studies have shown that, while current smokers believe smokers in general to be at higher risk for disease, they often perceive their own risk as lower than that of other smokers [17, 32, 33]. Studies identifying this smokers’ optimism phenomenon have concluded that smokers’ underestimation of their own risk will likely lead to an underestimation of the importance of quitting [17]. While our results related to health perceptions are consistent with other studies, we found that the percentage of current smokers in the sample who indicated they want to quit was lower (57.4%) than the 70% who want to quit in US population [35]. In addition, the proportion of smokers who made a quit attempt in the past year (30.5%) was lower than the proportion of smokers in the St. Louis Metro area (52.3%) who tried to quit in the last year [36]. This may be an indication that there is a stronger relationship between smoker optimism and cessation in this community than in the general population. Other modifying factors that have been linked to intention to quit include cultural smoking norms [37]. The lack of interest in cessation may stem from the underestimate of personal health risk, in addition to the Bosnian culture itself, where smoking is often considered ‘‘normal’’ behavior, going hand-in-hand with social exchange and coffee drinking [38, 39]. Similar to our results, one study of smoking among refugees found that smokers generally knew that smoking could be linked to serious health problems but only 50% were interested in smoking cessation at the time of the study. Reasons to continue smoking included helping them cope with life in the US, stress related to being a refugee in the United States [20], posttraumatic stress disorder and other mental health consequences of the war, the addictive nature of the nicotine, and the fear of gaining weight [18, 40, 41]. Findings such as these demonstrate the many factors that influence smoking behavior among Bosnian refugees and suggest it to be multifaceted as well as culturally different than the patterns we might find in other smokers in the United States. The influence of social acceptability and mental health consequences described above, along with the perceptions

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of risk among smokers in our sample, demonstrate that smoking behavior is complex in the Bosnian community. High smoking rates [19, 20] make identification and implementation of effective cessation interventions a priority and the complexity of smoking behavior should be considered when developing interventions. Models such as the Health Belief Model [42–45] and evidence related to minority, immigrant and refugee groups affected by tobacco-related disparities [46, 47], can help guide the identification and implementation of culturally-appropriate and tailored interventions or cues to action. Potential interventions could include an educational campaign aimed at changing perceptions about personal health risks related to smoking. As part of this campaign it would be important to increase the knowledge around the benefits of quitting and how these benefits outweigh perceived costs or barriers. In concert with education efforts, widespread provision of culturally competent information about, and access to, cessation programs and aids is an important strategy in helping smokers to successfully quit and stay quit [46]. Previous studies with St. Louis Bosnians also suggest the importance of delivering programs in Bosnian, as many of the middle aged and elderly community members speak limited English [48], and native language materials would be more trusted and better received [48]. To ensure that an education campaign reaches the community and that cessation aids are accessible and utilized, public health practitioners should consider developing partnerships in the refugee community they are trying to reach. Previous research has shown the importance of involving the community in education and intervention programs, and this is particularly true of collectivist communities such as the Bosnian community [49]. Because the relationship between smoking behavior and perceptions are complex in the Bosnian refugee community, future qualitative studies are also needed to gain an in-depth knowledge of the barriers to cessation unique to Bosnian refugees. Finally, a better understanding of the relationship between smoker optimism and interest in cessation is important to examine and may help guide future efforts to reduce Bosnian refugee smoking rates, as well as design other programs for ‘‘New Americans.’’

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