one and halffff

American Journal of Public Health | August 2006, Vol 96, No. 81342 | Commentary | Peer Reviewed | Abraído-Lanza

 COMMENTARY 

Toward a Theory-Driven Model of Acculturation in Public Health Research

| Ana F. Abraído-Lanza, PhD, Adria N. Armbrister, MA, Karen R. Flórez, MPH, and Alejandra N. Aguirre, MPHInterest in studying the impact of acculturation on immigrant health has in- creased in tandem with the growth of the Latino popu- lation in the United States. Linear assimilation models continue to dominate public health research despite the availability of more complex acculturation theories that propose multidimensional frameworks, reciprocal in- teractions between the indi- vidual and the environment, and other acculturative proc- esses among various Latino groups.

Because linear and uni- dimensional assessments (e.g., nativity, length of stay in the United States, and language use) provide con- stricted measures of accul- turation, the rare use of multidimensional accultura- tion measures and models has inhibited a more com- prehensive understanding of the association between specific components of ac- culturation and particular health outcomes. A public health perspective that in- corporates the roles of struc- tural and cultural forces in acculturation may help iden- tify mechanisms underlying links between acculturation and health among Latinos. (Am J Public Health. 2006; 96:1342–1346. doi:10.2105/ AJPH.2005.064980)

BECAUSE OF ITS ORIENTATION in and emphasis on health dis- parities, the field of public health should pay particular attention to the impact of acculturation on the health of Latinos. Latinos are currently the largest ethnic minority group in the United States, numbering 35.3 million persons and comprising 12.5% of the country’s population.1

Although the percentage varies across the different Latino groups, more than two thirds (65.2%) of Latinos (excluding Puerto Ricans) living in the United States are foreign-born.2

This large proportion of immi- grants illustrates, in part, the importance of considering acculturation in research on the health of Latinos.

Although definitions vary, ac- culturation is broadly described as the process by which individu- als adopt the attitudes, values, customs, beliefs, and behaviors of another culture.3,4 The process of acculturation presents numer- ous challenges and life changes that could potentially benefit or adversely affect the health of im- migrants as well as subsequent US-born generations. Therefore, it is important to consider accul- turation processes when studying the health of all Latinos in the United States.

In the social and behavioral sci- ences, there is a rich theoretical literature on acculturation; how- ever, models from this literature have not been applied to much public health research. Theoreti- cally grounded studies of accul- turation could provide effective

analytic tools for current efforts to address health disparities among Latinos. Because of its orientation toward and examination of large- scale structural and cultural forces that promote health, prevent dis- ease, and affect illness experi- ences, a public health perspective on acculturation may offer a deeper understanding of Latino health. Thus, a public health ap- proach could contribute much to the development and refinement of acculturation theory and simul- taneously address the health needs of Latino populations in the United States.

ACCULTURATION THEORY AND MEASUREMENT

Research on acculturation and health has not kept pace with ac- culturation theory. As illustrated in detailed reviews of the accul- turation literature,3–7 in the early 1900s numerous social scientists offered various acculturation the- ories. The most influential mod- els were set forth by sociologists from the human ecological school of thought, most notably Park.8 In essence, Park proposed a linear and directional process by which loss of the original cul- ture occurs through greater ac- culturation. Despite the evolution of more elaborate paradigms in the social and behavioral sci- ences, these linear assimilation models were adopted by much of the public health research on acculturation.

With few notable exceptions,9

reciprocal acculturation processes, or the influence of immigrant

groups on American society, re- main virtually untested,7 as do other more expansive contempo- rary theories. Such models posit orthogonal relations between the original and the new culture,10 re- sulting in various orientations that include biculturalism (e.g., strong adherence to both Mexican and American value systems). Other multidimensional models propose typologies on the basis of cultural awareness and ethnic loyalty.11

Still others postulate that immi- grants selectively adopt traits and behaviors from the new culture, especially those traits leading to increased economic and social mobility, while maintaining cer- tain values from their original culture.3,4

There are numerous scales available to measure accultura- tion, perhaps reflecting its di- verse conceptualizations. Al- though the measurement of acculturation is a matter of con- troversy and debate12 in public health literature, indexes of ac- culturation that predominate are nativity or generational status, length of residence in the United States, and language use. These simple descriptors are useful in laying the groundwork for acculturation and for de- scribing the heterogeneity of the Latino population, but they are limited in their ability to capture all the nuances of acculturation and to tap directly immigrants’ adherence to American values. Furthermore, such proxy mea- sures largely reflect the linear and directional assumption of earlier acculturation theories. To

August 2006, Vol 96, No. 8 | American Journal of Public Health Abraído-Lanza | Peer Reviewed | Commentary | 1343

 COMMENTARY 

address some of these problems, multidimensional scales have been developed to tap domains such as language, food, and music preferences; the extent of social ties and contacts with friends of the same ethnic group; parents’ place of birth; ethnic identity; and social affilia- tion with Latinos versus Anglos.9,13,14 However, many of these scales are scored by sum- ming across items (with greater scores reflecting strong adher- ence to Anglo culture). Such procedures minimize the utility of measuring the multiple di- mensions of acculturation.15,16

Greater advances in research on acculturation and health could be made if acculturation were represented as a “latent variable” with various indicators. This allows the measurement of Latino cultural “worldviews” or belief systems, values (e.g., indi- vidualism vs familialism), linguis- tic preferences, and other behav- iors and preferences, which would represent the latent vari- able of acculturation. Moreover, the use of more elaborate statis- tical techniques, such as struc- tural equations,17 allows for the associations between specific in- dicators of acculturation and var- ious health outcomes to be mod- eled. Furthermore, because health behaviors encompass a disparate array of variables, ranging from dietary practices to the use of social support systems, acculturation may be measured best by considering factors rele- vant to the particular health issue at hand, rather than by a monolithic “acculturation” con- cept. For example, research on obesity may be best served by asking specific acculturation questions on nutrition (e.g., ad- herence to “traditional” diets consisting of low-fat foods such

as beans, rice, and vegetables) or other culturally based behaviors (e.g., attitudes about exercise). This would help identify the spe- cific components of acculturation that are associated with particu- lar health outcomes.18

Many existing theories and scales disregard historical, socie- tal, and other structural factors, as well as social dynamics that promote and maintain specific acculturation orientations or pat- terns, such as biculturalism. Pochismo, which is the fusion and crystallization of American and Mexican cultural elements that evolved among Mexican Ameri- cans of the southern border of the United States,19 is a salient example of this type of bicultur- alism. In fact, pochismo could be considered a distinct and free- standing culture with its own language (Spanglish), music, and identity that evolved from the dynamic and reciprocal interac- tion of Mexican and American cultures in the border region and that would prove very difficult to assess with current acculturation measures.

As described in subsequent sections, however, historical and sociopolitical factors that influ- ence immigration vary across the different Latino groups. There- fore, the specific types of social and structural factors that should be taken into account may de- pend on the particular Latino group being studied.

ACCULTURATION AS A HEALTH RISK OR A PROTECTIVE FACTOR

The integration of accultura- tion theory into public health re- search could advance the study of various Latino health issues. With respect to global health indicators, such as all-cause

mortality and life expectancy, there is growing evidence of bet- ter health among Latinos than among non-Latino Whites.20–24

However, high levels of accul- turation among Latinos are asso- ciated with increased rates of cancer, infant mortality, and other indicators of poor physical and mental health.3,25 With some exceptions,26 rates of risky health behaviors (e.g., smoking, alcohol use, high body mass index) also increase with accul- turation.17,23,27–33 These findings suggest that, in the process of acculturation, Latinos may be exposed to different risk factors or may adopt unhealthy behav- iors that result in shifts in mor- bidity and mortality for various diseases.

The results are not all nega- tive, however. Although accul- turation is a “risk factor” for myriad unhealthy behaviors, there is also some evidence that it is associated with several healthy behaviors, such as greater exercise and leisure-time physical activity.17,27,28,34 The observations that acculturation can be both a risk and a protec- tive factor for various health be- haviors requires further study.17

However, research on these is- sues has been hampered by the measurement problems de- scribed in the previous section. For example, multidimensional scales may be useful in identify- ing specific components of ac- culturation, such as norms con- cerning smoking or alcohol consumption, that present risk or protective factors for particu- lar health problems, such as to- bacco use or binge drinking.9

The role of acculturation as a risk and protective factor also raises some intriguing theoreti- cal issues and unanswered questions.

NEED FOR THEORETICAL MODELS

Despite growing evidence of the association between accul- turation and health behaviors among Latinos in the United States, few theories have been proposed to explain these ef- fects. In general, there is a great lack of theoretical models on ac- culturation and physical health outcomes.35

Acculturation may be a proxy for other variables, such as pro- longed exposure to stressful events or adverse circumstances, including those associated with immigration and eventual settle- ment, or disadvantaged social status. Although proxy variables have not been fully investigated, the adverse effect of accultura- tion on health is not always at- tenuated when adjusting for so- cial disadvantage confounders (specifically, socioeconomic sta- tus).17,25 To date, there is a lack of research on theoretical models concerning the mechanisms by which acculturation affects health. Acculturation may affect health behaviors as a conse- quence of coping responses to discrimination and poverty; loss of social networks; exposure to different models of health behav- ior; and changes in identity, be- havioral prescriptions, beliefs, values, or norms.

An underlying assumption in the literature is that beliefs or norms concerning particular be- haviors change with greater ac- culturation. These mutable be- liefs and norms are seldom tested, however. One recent study indicated that the majority (almost 75%) of less accultur- ated Latinas considered it worse to be a smoker than to be obese, and the majority (nearly 75%) of more acculturated Latinas

American Journal of Public Health | August 2006, Vol 96, No. 81344 | Commentary | Peer Reviewed | Abraído-Lanza

 COMMENTARY 

held the opposite opinion.36 If we assume that these norms are reflected in women’s behavior concerning smoking and mainte- nance of weight, they are consis- tent with some observations in the literature (e.g., that accultura- tion increases the odds of smok- ing and exercise among Lati- nas)27,28,37,38 but not others (e.g., that acculturation increases the likelihood of high body mass index).27,28,30

Overall, changes in values, belief systems, and worldviews have remained unexplored in public health research on accul- turation and health outcomes. Yet a growing literature docu- ments the importance of consid- ering the impact of acculturation on these psychosocial variables and their role in shaping the health of Latinos.35,39 Whether cultural values and other psycho- social mechanisms—as well as their associated effects on health—decline with greater ac- culturation remains a question for further research.

ACCULTURATION TO WHAT?

Another critical theoretical question concerns the reference culture to which Latinos are ac- culturating. Although the refer- ence group is not always speci- fied,12 implicit in much research on acculturation is the unwritten understanding that White Ameri- cans are the standard makers for “American-ness.” In many studies and measures, the assumption is that increased acculturation brings immigrants’ values and be- haviors in line with a standard- ized set of values, primarily those associated with “White American culture.”16(p39) Positing that White culture is the reference point for acculturation may misrepresent

acculturation and limit the under- standing of complex health re- sponses and outcomes among Latinos. Therefore, a fuller understanding of acculturation processes among Latinos must in- clude the interactions of Latinos with other groups of color (whose ability to disappear in the main- stream is limited). This approach must take into consideration the prevalence of racial conflict and the degree to which the dualistic racial system is embedded in the United States.40

Segmented assimilation the- ory, which portrays immigrants and their subsequent generations as complex and active members of their lived environments, pre- sents an alternative to the as- sumption that White culture is invariably the reference point for acculturation.5 Segmented assimi- lation refers to diverse patterns of adaptation whereby immigrant groups differentially adopt the attitudes, beliefs, and behaviors of divergent cultural groups in the United States. For example, whereas some second-generation Haitian adolescents do follow a “standard” pattern of assimilation to middle-class White America, others adopt the values and norms of Black inner-city youth.40

Thus, the segmented assimilation framework documents various potential patterns of accultura- tion, highlighting the importance of considering varied reference groups and diverse patterns of adaptation.

Pivotal to the concept of seg- mented assimilation is the ac- knowledgment of structural con- straints faced by ethnic minority groups, who often reside in large metropolitan areas with high rates of residential segregation and racism.41 Often, the synergis- tic effects of segregation and racism isolate residents from

amenities and services and con- centrate large numbers of mi- norities in economically disad- vantaged urban areas. The inevitable interaction occurring at economic, political, cultural, and social levels between differ- ent ethnic groups living in multi- ethnic neighborhoods (e.g., Do- minicans living with African Americans in the South Bronx) is largely neglected by the accultur- ation literature. A paucity of studies attempt to measure the extent to which Latinos report closeness or ideological familiar- ity with African Americans.42

We are aware of no public health studies that examine whether Latinos adopt the culture of other ethnic minority populations in the United States, how struc- tural factors (e.g., residential seg- regation) may operate to promote “ethnic minority acculturation,” or the impact of this process on health.

Issues such as acculturation in the context of residential segrega- tion, racism, and other deleteri- ous aspects of life as a minority in the United States demand at- tention from a forward-thinking public health research commu- nity. Equally important to this reconceptualized version of ac- culturation is the exploration of how ethnic enclaves might affect health positively or negatively through cultural, economic, and social mechanisms.5,40 A public health approach should consider contextual and structural factors in acculturation and challenge the popular notion of White American culture as the “accul- turation standard.” This approach could offer some innovative methods to understand health disparities in lived environments while also effectively describing the reality of minority groups in the United States.

GENDER AND AGE

Research is also needed to bet- ter understand why the effect of acculturation on certain health behaviors varies by gender and age or developmental stage. For example, as Latino men and women acculturate, their alco- hol use and smoking patterns reflect the gender-related behav- ioral norms in the United States.31,33,38,43 In studies of youths, greater acculturation in- creases the likelihood of alcohol use and smoking44–46; however, acculturation operates with other psychosocial factors pertinent to the adolescent life stage (e.g., peer influence, low self-esteem, self-efficacy to resist smoking and alcohol use) to determine risky health behaviors.47–49 Such find- ings challenge the assumption of a direct relation between accul- turation and health behaviors. These findings further illustrate the need for more comprehen- sive theoretical models that in- corporate structural and contex- tual factors, as well as mediating variables, to explain the associa- tion between acculturation and health among Latinos in the United States. Further studies should also examine whether be- haviors that are attributed to ac- culturation (e.g., tobacco and al- cohol use), instead reflect stages of development or gender norms.

THE COMPLEXITIES OF “CULTURE”

Simplifying culture into “eth- nic,” “assimilated,” or other “risk” categories (e.g., “high” vs “low” acculturation) can inadvertently fuel weak explanations of health disparities by focusing attention on culture rather than on struc- tural constraints (e.g., lack of ac- cess to resources).50 Yet much

August 2006, Vol 96, No. 8 | American Journal of Public Health Abraído-Lanza | Peer Reviewed | Commentary | 1345

 COMMENTARY 

current research uses proxies of culture and acculturation without examining the societal contexts that promote or inhibit health. The role of individual agency on health can be overestimated if structural constraints are not con- sidered.51 For example, US immi- gration policy was amenable to Cuban immigrants fleeing the Castro regime (especially in the 1960s–1970s), and federal set- tlement-assistance programs (e.g., the US Migration and Refugee Assistance Act of 196252) were established specifically to assist them. Partly because of the up- ward social mobility afforded by these programs, today Cubans are among the most healthy of all long-standing Latino groups in the United States.25

Other groups seeking political asylum (e.g., Salvadorans and Mariel Cubans), however, were treated to noticeably less hospi- tality. What is the impact (if any) of these historical and po- litical factors on acculturation processes and health outcomes, and how might they contribute to different patterns among the various Latino groups in the United States? Although the contextual features of accultura- tion (e.g., circumstances before immigrating, the political and social climate of the United States upon arrival) could deter- mine the extent to which indi- viduals and heterogeneous La- tino groups adapt to new environments, these contexts are rarely studied.15,17,40

The complexity of these issues led some researchers to suggest that the use of acculturation measures be suspended.12 We disagree with this recommenda- tion. Instead, we propose that to understand Latino realities in the United States, it is critical to describe the context in which

ongoing cultural negotiations take place and the dynamics that reproduce and reconfig- ure “Latino culture” according to the equally complex American settings in which immigrants and other people of color find them- selves. A consideration of the intersection of large-scale social forces and culture is critical to stimulating the exploration of much-neglected sociological con- cepts, namely, class and power dynamics in the public health lit- erature on acculturation. Such avenues of research could prove to be fruitful in explaining the complexities surrounding Latino acculturation and health in the United States.

CONCLUSIONS

Although we raise more ques- tions than we answer, we pro- pose that a theory-based public health framework could con- tribute much to understanding the factors and mechanisms un- derlying the association between acculturation and health among Latinos. If cultural norms, beliefs, and values as well as broader structural factors are considered, a public health research agenda on acculturation and health may help to shift the paradigm from linear models to models that are multidimensional and more comprehensive. A public health framework offers the promising opportunity to build new para- digms that incorporate and ex- pand on social and behavioral science acculturation theories and that cross disciplinary boundaries. There is no doubt that Latinos in the United States face many hardships (e.g., pov- erty, inadequate access to health care, discrimination). However, perhaps it is time to identify and differentiate the cultural

resources and structural factors that better explain how accultur- ation affects health.

About the Authors All authors are with the Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY.

Requests for reprints should be sent to Ana Abraído-Lanza, PhD, Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, 722 West 168 St, 5th floor, New York, NY 10032 (e-mail: [email protected]).

This article was accepted September 23, 2005.

Contributors A. Abraído-Lanza originated the article and took the lead role in its writing. All authors participated in the literature re- view and in the writing and revising of the article.

Acknowledgments Support for preparing this manuscript was provided by the Initiative for Minor- ity Student Development at Columbia’s Mailman School of Public Health, an ed- ucation project funded by the National Institute of General Medical Sciences (R25GM62454), by the National Can- cer Institute (R03CA107876), and by the Columbia Center for the Health of Urban Minorities, funded by the Na- tional Center on Minority Health and Health Disparities (P60MD00206).

We give special thanks to Antonio T. Abraído.

References 1. US Census Bureau. The Hispanic Pop- ulation: Census 2000 Brief. Available at: http://www.census.gov/prod/2001pubs/ c2kbr01-3.pdf. Accessed April 21, 2006.

2. Population Profile of the United States: 1997. Washington, DC: US Bureau of the Census; 1998. Current Population Reports Series P23–194.

3. Clark L, Hofsess L. Acculturation. In: Loue S, ed. Handbook of Immigrant Health. New York, NY: Plenum Press; 1998:37–59.

4. LaFromboise T, Coleman HLK, Gerton J. Psychological impact of bicul- turalism: evidence and theory. Psychol Bull. 1993;114:395–412.

5. Zhou M. Segmented assimilation: issues, controversies, and recent re- search on the new second generation. Int Migration Rev. 1997;31:975–1008.

6. Rudmin FW. Critical history of the

acculturation psychology of assimilation, separation, integration, and marginaliza- tion. Rev Gen Psychol. 2003;7:3–37.

7. Teske RHC, Nelson BH. Accultura- tion and assimilation: a clarification. Am Ethnologist. 1974;1:351–367.

8. Park RE. Human migration and the marginal man. Am J Sociol. 1928; 33:881–893.

9. Hazuda HP, Stern MP, Haffner SM. Acculturation and assimilation among Mexican Americans: scales and population- based data. Soc Sci Q. 1988;69: 687–705.

10. Berry JW. Conceptual approaches to acculturation. In: Chun KM, Balls Organista P, Marín G, eds. Acculturation: Advances in Theory, Measurement and Applied Research. Washington, DC: American Psychological Association; 2003:17–37.

11. Padilla AM. Bicultural develop- ment: a theoretical and empirical exami- nation. In: Malgady RG, Rodriguez O, eds. Theoretical and Conceptual Issues in Hispanic Mental Health. Malabar, Fla: Krieger; 1994;19–51.

12. Hunt L, Schneider S, Comer B. Should “acculturation” be a variable in health research? A critical review of re- search on US Hispanics. Soc Sci Med. 2004;59:973–986.

13. Cuellar I, Arnold B, Maldonado R. Acculturation rating scale for Mexican Americans, II: a revision of the original ARSMA scale. Hispanic J Behav Sci. 1995;17:275–304.

14. Szapocznik J, Kurtines WM, Fernandez T. Bicultural involvement and adjustment in Hispanic-American youths. Int J Intercultural Relations. 1980;4:353–365.

15. Cabassa LJ. Measuring accultura- tion: where we are and where we need to go. Hispanic J Behav Sci. 2003;25: 127–146.

16. Zane N, Mak W. Major approaches to the measurement of acculturation among ethnic minority populations: a con- tent analysis and an alternative empirical strategy. In: Chun KM, Balls Organista P, Marín G, eds. Acculturation: Advances in Theory, Measurement and Applied Re- search. Washington, DC: American Psy- chological Association; 2003:39–60.

17. Lara M, Gamboa C, Kahramanian I, Morales L, Bautista D. Acculturation and Latino health in the United States: a review of the literature and its socio- political context. Ann Rev Public Health. 2005;26:367–397.

18. National Heart, Lung, and Blood Institute Web page. Epidemiologic Re- search in Hispanic Populations Oppor- tunities, Barriers and Solutions. Work- ing Group July 31–August 1, 2003,

American Journal of Public Health | August 2006, Vol 96, No. 81346 | Commentary | Peer Reviewed | Abraído-Lanza

 COMMENTARY 

Bethesda, Md. Available at: http://www. nhlbi.nih.gov/meetings/workshops/ hispanic.htm. Accessed April 11, 2006.

19. González Gutiérrez C. Fostering identities: Mexico’s relationship with its di- aspora. J Am History. 1999;86:545–567.

20. Abraído-Lanza AF, Dohrenwend BP, Ng-Mak DS, Turner JB. The Latino mortality paradox: a test of the “salmon bias” and healthy migrant hypotheses. Am J Public Health. 1999;89:1543–1548.

21. Hummer RA, Rogers RG, Amir SH, Forbes D, Frisbie WP. Adult mortality differentials among Hispanic subgroups and non-Hispanic whites. Soc Sci Q. 2000;81:459–476.

22. Lin CC, Rogot E, Johnson NJ, Sorlie PD, Arias E. A further study of life expectancy by socioeconomic factors in the National Longitudinal Mortality Study. Ethn Dis. 2003;13:240–247.

23. Singh GK, Siahpush M. Ethnic- immigrant differentials in health behav- iors, morbidity, and cause-specific mor- tality in the United States: an analysis of two national databases. Hum Biol. 2002;74:83–109.

24. Sorlie PD, Backlund E, Johnson NJ, Rogot E. Mortality by Hispanic status in the United States. JAMA. 1993;270: 2464–2468.

25. Vega WA, Amaro H. Latino out- look: good health, uncertain prognosis. Annu Rev Public Health. 1994;15:39–67.

26. Hazuda HP, Haffner SM, Stern MP, Clayton WE. Effects of accultura- tion and socioeconomic status on obe- sity and diabetes in Mexican Ameri- cans. Am J Epidemiol. 1988;128: 1289–1301.

27. Abraído-Lanza AF, Chao MT, Flórez KR. Do healthy behaviors de- cline with greater acculturation? Impli- cations for the Latino mortality paradox. Soc Sci Med. 2005;61:1243–1255.

28. Cantero PJ, Richardson JL, Baezconde-Garbanati L, Marks G. The association between acculturation and health practices among middle-aged and elderly Latinas. Ethn Dis. 1999;9: 166–180.

29. Gordon-Larsen P, Harris KM, Ward DS, Popkin BM. Acculturation and overweight-related behaviors among Hispanic immigrants to the United States: the National Longitudinal study of adolescent health. Soc Sci Med. 2003;57:2023–2034.

30. Himmelgreen DA, Pérez-Escamilla R, Martinez D, et al. The longer you stay, the bigger you get: length of time and language use in the US are associated with obesity in Puerto Rican Women. Am J Phys Anthropol. 2004;25:90–96.

31. Marks G, Garcia M, Solis JM.

Health risk behaviors of Hispanics in the United States: findings from HHANES, 1982–84. Am J Public Health. 1990;80(suppl):20–26.

32. Marín G, Posner SF. The role of gender and acculturation on determin- ing the consumption of alcoholic bever- ages among Mexican-Americans and Central Americans in the United States. Int J Addict. 1995;30:779–794.

33. Pérez-Stable EJ, Ramirez A, Villareal R, et al. Cigarette smoking be- havior among US Latino men and women from different countries of origin. Am J Public Health. 2001;91:1424–1430.

34. Crespo CJ, Smit E, Carter-Pokras O, Andersen RE. Acculturation and leisure- time physical inactivity in Mexican American adults: results from NHANES III, 1988–1994. Am J Public Health. 2001;91:1254–1257.

35. Myers H, Rodriguez N. Accultura- tion and physical health in racial and ethnic minorities. In: Chun KM, Balls Organista P, Marín G, eds. Acculturation: Advances in Theory, Measurement and Applied Research. Washington, DC: American Psychological Association; 2003:163–185.

36. Johnsen L, Spring B, Pingitore R, Sommerfeld BK, MacKirnan D. Smoking as subculture? Influence on Hispanic and non-Hispanic white women’s atti- tudes toward smoking and obesity. Health Psychol. 2002;21:279–287.

37. Haynes SG, Harvey C, Montes H, Nickens H, Cohen BH. Patterns of ciga- rette smoking among Hispanics in the United States: results from HHANES 1982–1984. Am J Public Health. 1990; 80(suppl):47–53.

38. Marín G, Pérez-Stable EJ, Marín BV. Cigarette smoking among San Fran- cisco Hispanics: the role of acculturation and gender. Am J Public Health. 1989; 79:196–198.

39. Marín G, Gamba RJ. Acculturation and changes in cultural values. In: Chun KM, Balls Organista P, Marín G, eds. Acculturation: Advances in Theory, Measurement and Applied Research. Washington, DC: American Psychologi- cal Association; 2003:83–93.

40. Portes A, Zhou M. The new sec- ond generation: segmented assimilation and its variants. Ann Am Acad Political Soc Sci. 1993;530:74–96.

41. Charles CZ. The dynamics of racial residential segregation. Annu Rev Sociol. 2003;29:167–207.

42. Norris AE, Ford K, Bova CA. Psy- chometrics of a brief acculturation scale for Hispanics in a probability sample of urban Hispanic adolescents and young adults. Hispanic J Behav Sci. 1996;18: 29–38.

43. Markides KS, Ray LA, Stroup- Benham CA, Trevizo F. Acculturation and alcohol consumption in the Mexi- can American population of the South- western United States: findings from HHANES 1982–84. Am J Public Health. 1990;80(suppl):42–46.

44. Epstein JA, Botvin GJ, Diaz T. Linguistic acculturation and gender effects on smoking among Hispanic youth. Prev Med 1998;27:583–589.

45. Kaplan CP, Napoles-Springer A, Stewart SL, Perez-Stable EJ. Smoking acquisition among adolescents and young Latinas: the role of socioenviron- mental and personal factors. Addict Behav. 2001;26:531–550.

46. Guilamo-Ramos V, Jaccard J, Johansson M, Tunisi R. Binge drinking among Latino youth: role of acculturation- related variables. Psychol Addict Behav. 2004;18:135–142.

47. Morgan-Lopez AA, Gonzalez Castro F, Chassin L, MacKinnon DP. A mediated moderation model of cigarette use among Mexican American youth. Addict Behav. 2003;28:583–589.

48. Bettes BA, Dusenbury L, Kerner J, James-Ortiz S, Botvin GJ. Ethnicity and psychosocial factors in alcohol and to- bacco use in adolescence. Child Dev. 1990;61:557–565.

49. Unger JB, Cruz TB, Rohrbach LA, et al. English language use as a risk factor for smoking initiation among Hispanic and Asian American adoles- cents: evidence for mediation by tobacco- related beliefs and social norms. Health Psychol. 2000;19:403–410.

50. Link B, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav 1995;35 (extra issue):80–94.

51. Farmer P. Infections and Inequali- ties. Berkeley, Calif: University of Cali- fornia Press; 1999.

52. US Migration and Refugee Assis- tance Act of 1962. Available at: http:// www.lib.umich.edu/govdocs/jfkeo/eo/ 11077.htm. Accessed April 21, 2006.