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Latinos are the largest minority group in the United States, and in California they outnumber non-Hispanic whites. Smoking cessation programs tailored for Latino culture, and this population’s specific smoking patterns, are needed. Online social networks for smoking cessation have high potential for Latinos, but have not been tested to date.
Building a research program on social media apps for cancer prevention in diverse populations, this qualitative study assessed acceptability of tobacco treatment that was distributed via social media for Latino smokers.
We conducted three focus groups with Latino adults who were former and current smokers recruited from Santa Clara County, California in 2015 (N=32). We assessed participants’ smoking histories, attempts to quit, social media exposure, and receptivity to a social media-based smoking cessation intervention. Audio transcripts were translated and coded for themes.
Participants reported factors driving their tobacco use and motivations to quit, and emphasized the importance of community and family in influencing their smoking initiation, cravings and triggers, attempts to quit, and abstinence. Participants valued the communal aspect of social media and suggested strategically tailoring groups based on key features (eg, age, gender, language preference). Participants reported preferring visual, educational, and motivational messages that were connected with existing services.
Participants generally voiced acceptability of a social media-delivered intervention to help them quit smoking, viewed the intervention as well-equipped for catering to the strong community orientation of Latinos, and suggested that the platform was able to address variation within the population through strategic group creation. As a group member reflected, “Podemos hacerlo juntos” (We can do it together).
Tobacco is the leading preventable cause of death, and is linked to a dozen types of cancer, along with heart and lung disease [
Tailoring of cessation treatment strategies to target audiences has been a strategy for increasing reach and engagement. In the early 1990s, a printed Spanish-language smoking cessation guide was found to support quitting and was distributed as a best practice [
Online social media sites allow real-time interactivity and peer-to-peer support, which may build upon cultural norms and values, with potentially low-cost application for disseminating health interventions to diverse groups. Furthermore, communications generated and catalogued on social media sites provide novel information for better understanding transitions in smoking and emerging product use (eg, electronic cigarettes; e-cigarettes). Twitter is the dominant open social media site, with a reported 320 million active monthly users, representing growth of 9.6% over the same period a year prior [
Social media is likely to be a viable platform for Latino adult smokers, given the widespread use of the Internet, particularly for the dissemination of health information. A 2010 Pew Hispanic Center study reported that 83% of Latinos received health information from media sources, including 35% online [
To inform a social network-based smoking cessation program, we conducted focus groups with Latinos who were current and former smokers to determine if a tobacco cessation treatment distributed via social media would be acceptable. Secondary research aims were: gathering information and feedback about local Latino smoking profiles, attempts to quit, and social media exposure to inform the intervention strategy and community outreach efforts.
Participants were recruited via online classified advertisements (Craigslist), in person by community health workers, and through word-of-mouth in Santa Clara County. Inclusion criteria were: age 18 years or older; identifying as Latino/Latina; residing in the Santa Clara County area; and status as a current daily, social, or former smoker.
The focus group moderator was fluent in Spanish and English. The groups were semistructured. The moderator guide prompted questions about mobile phone and social media use, smoking, quitting smoking, and treatment preferences. An initial survey assessed participants’ demographic and smoking history information. Study procedures were approved by the Stanford Institutional Review Board; all participants provided signed informed consent in Spanish or English, were compensated US $50 for their time, and received a meal during the focus group session.
Each focus group was audio recorded. A Spanish/English bilingual coder listened to the focus group audio recordings and outlined initial coding themes, which were discussed and refined by the research team. The audio recordings were simultaneously translated and transcribed to a final written transcription in English. Using a detailed codebook, the same bilingual team member then coded the written transcripts for emergent and preidentified themes of interest using Dedoose [
A total of 32 individuals (15 men, 17 women) from Santa Clara County, California participated. Participants included 19 current daily smokers, 4 intermittent or nondaily smokers, and 9 former smokers. Daily smokers averaged 8.4 cigarettes per day (standard deviation [SD] 10.4, range 1-40) and nondaily smokers averaged 4.3 cigarettes per week (SD 3.8, range 1-8). Current smokers reported time to first cigarette upon waking within 5 minutes (3/23, 13%), between 6-30 minutes (3/23, 13%), between 31-60 minutes (6/23, 26%), and greater than 60 minutes (11/23, 48%). Factors that kept participants from smoking sooner included children, having to go outside to smoke, TV, and checking Facebook. Participants reported getting their cigarettes from friends (n=15), gas stations (n=13), liquor stores (n=12), and corner stores (n=12).
All participants had made at least one 24-hour attempt to quit smoking (range 1-7). Identified reasons for quitting related to money, work, a home smoking ban, family and friends, cancer fears, sports, and not feeling the urge to smoke. Among the 23 current smokers, 6 (26%) were not intending to quit in the near future (precontemplation), 7 (30%) intended to quit in the next six months (contemplation), and 10 (43%) were planning to quit in the next month (preparation). Three individuals reported assistance for quitting smoking from a medical provider. Only one respondent reported using nicotine replacement. No participants reported using other cessation medications or formal psychosocial supports to quit (eg, group or individual counseling, quit-line).
Most participants owned a smartphone (27/32, 84%), and all but one kept their phone with them every day. The majority of respondents reported having their phone turned on all the time (20/32, 63%), texting on their phone more than once daily (26/32, 81%), and checking their Facebook page at least once daily (22/32, 69%).
At the start of the focus groups, in a word association task (ie, “What word comes to mind when you think of smoking?”), participants connected smoking to negative health and social effects in the following order of frequency: cancer, money, aging skin, and guilt. Participants also identified positive aspects of smoking, including social activity, calming, weight loss, and hobby.
Triggers for smoking were mentioned throughout the focus group conversations. In order of frequency (with counts indicated) participants identified: stress from school, work, family, and traffic (11); negative emotions such as anger and anxiety (6); alcohol use (4); other habitual triggers (4); others smoking (3); work breaks (2); boredom (2); seeking relaxation (2); and smoking for gastrointestinal regularity (1). Notably, social media was not identified as a trigger to smoke.
While a minority of participants were former smokers, all had experience with quitting for at least 24-hours. Motivations for quitting centered around family, including children, siblings, partners, and parents:
I would hide my cigarettes, I used perfume so that my son couldn’t smell the cigarette, I would wash my hands, but on one occasion he looked at me and he said, “Oh, you’re smoking!” I felt like a bucket full of water fell over me, he said, “Do you want to die? If you don’t care about me, continue smoking.” His words hurt me so much that in 15 days I quit because I thought that a cigarette was not more important than my son. It was very hard, I had terrible headaches, shaking… but the love for my son is what helped me quit smoking.”
Life transitions were a common theme, overlapping with family concerns, as pregnancies and new babies were prominent transitions. Two women and a man successfully quit smoking during a family pregnancy. As one woman shared:
Another woman described her shame and concerns around not being able to quit during pregnancy:
My last pregnancy - I did smoke. It caused me a lot of pain, and I have four children with asthma because I smoked when I would breastfeed. My youngest girl also has asthma. I’ve always had bronchial disease, and my kids would tell me, “I don’t want you to die.” I knew it was wrong, but I would get mad, or I’d get sad, and I would get out to smoke. Sometimes I get an urge to smoke, but I love my children a lot, and I want to live for them.
Additional influences identified as motivating cessation were religious faith, medical advice, and financial and health concerns. One participant said her sister became a Christian and stopped smoking, while another shared her promise to God to quit smoking. A third participant shared, “I always would ask my God, ‘You know what? I can’t do this alone, help me to give up this obsession.’”
The importance of social support and community were identified as themes. Participants noted that
Sometimes people need to be in a group to be able to see how other people are trying hard to quit in order to encourage themselves to quit too. Some people are in this country and they are alone, so I think [support] would help them.
Participants reported using various social media platforms, including Facebook, Twitter, Instagram, Skype, Yahoo, and Snapchat. The groups stated a strong preference for Facebook and visual messages. The overall sentiment across groups was acceptability of social media as a vehicle for smoking cessation programs. One participant stated, “I think this idea is very good because… we’re 100% cybernetic… and [social media] is the right weapon to use.” Another asserted, “I think it would be a magnificent idea because… I have people on there [Facebook] that put they feel bad… and we send them a message, and it helps.” Furthermore, social media smoking cessation groups were imagined as supportive of quitting, in contrast to existing social networks of smokers who may encourage continued smoking. Participants also liked the idea of knowing that strangers in a group would withhold judgment toward any failed quit attempts.
Not all participants agreed, however, with one participant stating that his family and friends would be better able to support his quitting compared to, “a group of strangers.” One participant resisted the idea of spending more time on her phone, noting that as a parent her time at home is already too hectic. Another respondent voiced concern, explaining:
Participants discussed whether the groups should be matched on salient characteristics. One social smoker wanted to be in a group of nondaily social smokers. Another participant suggested creating groups based on common interests, similar to what is done on “dating sites.” A discussion centered on matching participants by age. One young adult participant stated, “If I see a young person trying to stop… we can do it together.” Another participant voiced potential benefits of mixed-age groups, stating:
different ages could help. I know that for the young ones, the pressure they have is very difficult, even more if they’re in school, they get stressed out, and they want to relax. So having an adult in that group who has more knowledge could be beneficial to them.
Other respondents encouraged the idea of keeping age unknown. One participant, with the perspective that age should not matter, asserted, “Cancer doesn’t look at ages, or race.” Another participant reflected:
Regarding language preference for a Latino-focused smoking cessation intervention on social media, 7 participants preferred a mixed English/Spanish platform, 4 preferred Spanish only, and 1 preferred English only. Three additional participants did not have a preference, and opted for group leaders to choose. The other 17 participants did not voice a preference. All participants, except the one who preferred English only, reported that Spanish was their dominant language.
Participants shared advice on the types of smoking messages that would be most effective for individuals trying to quit smoking. There was a preference for nonforceful communication with no demanding messages, such as, “Don’t push; we’ll do it because we want to do it.” Preferred messages were educational and provided motivation and support. One participant emphasized, “It’s important that we know why we are making the decision to quit. It’s good to help us understand why we made decisions to quit.” Participants also recommended linking social media cessation interventions with existing support systems and services, such as the national smokers quit-line (1-800-QUIT-NOW).
The use of visual images was also encouraged, reflected by the quote, “A picture has a bigger impact than a word.” One participant shared, “I have a friend and he’s a doctor and he continuously post lungs… [and information] about cigarette filters.” Two participants stated that it was uncommon to see images or information about smoking on social media, while others noted postings of drinking and smoking at parties rather than encouragement to quit.
Despite not being part of the discussion guide, e-cigarettes represented an emergent topic with a variety of expressed opinions. Some participants were positive towards e-cigarettes with assertions that, “They’re not as bad as cigarettes”, “They’re cheaper than tobacco”, and not a “bother” to others with a bad smell. Participants reported seeing e-cigarette advertising cessation claims, although no respondent reported successfully quitting smoking using e-cigarettes. Participants reported a willingness to try e-cigarettes, largely out of curiosity instead of a desire to quit smoking.
Latino smokers and recent former smokers from the Bay Area of California largely found the concept of a social media tobacco cessation intervention acceptable. Social media was perceived to be well-equipped to meet the social- and community-oriented experiences of Latinos. Participants also noted that social media could allow for further tailoring of support groups based on homophilous characteristics related to age, smoking frequency, and language preference. A preference was stated for Facebook, due to participant familiarity with the platform and the ability to leverage visual as well as text-based content. Visual communication of health information improves comprehension, and enhances attention, memory, and recall [
Focus groups have been used in research to explore the experience of smoking cessation among ethnic minorities and have highlighted the importance of considering levels of acculturation in program tailoring [
Family orientation, social support, and community were prevailing themes in the focus group discussions of smoking, attempts to quit, and social media use, providing a basis for why social media may be particularly well-suited for a Latino-focused smoking cessation intervention. Participants noted the opportunities for community-building in social media venues, which have not previously been available through traditional websites or quit-line interventions. The Latino experience of quitting smoking is also conceptualized as a family or group effort, and social media may address previous calls to tailor interventions for racial/ethnic-specific processes for quitting.
As a local qualitative study, the generalizability of our results is limited. The group moderator was fluent in Spanish, and coding was done via listening in Spanish; however, the final analysis of transcripts was conducted in English, which may have reduced or changed content in unpredictable ways. Despite these limitations, findings with respect to acceptability of social media, importance of family in health behavior change, and preference for visual material are likely broadly relevant.
In conclusion, a social media-delivered intervention to support smoking cessation appears to be acceptable for Latino smokers. Regarding immediate implications, the study findings support efforts to develop novel interventions for treating tobacco use via social media. These interventions may be tested as standalone cessation programs or as adjuncts to existing treatments. For cultural relevance, message themes within the program should attend to family and community ties and influences. For maximum engagement and inclusiveness, flexibility in language use (ie, English, Spanish, both) should be permitted and encouraged. The specific social media platform may be determined by usage rates and fit of the technology for the intervention’s approach and privacy concerns. Regardless of platform, community outreach and engagement is essential to treatment impact, and Latino smokers’ tobacco purchasing behaviors may inform channel selection. Based on the focus groups, places to promote a social media quit smoking program would include in gas stations, liquor stores, and corner stores, near where cigarettes are displayed, as well as via word-of-mouth referrals from friends.
The use of social media by Latinos is high; however, the use of these media for health behavior change appears to be underdeveloped. As such, our next steps will center on developing and testing a Latino-specific, bilingual, private, support group-based social media intervention for smoking cessation. The examination of homophily in group communications will be of particular interest, to determine whether directed and reciprocated communications align around shared member characteristics (eg, gender, age, daily/nondaily smoking status, language preference).
electronic cigarette
standard deviation
This study was funded by the Stanford Cancer Institute and by a State of California Tobacco Related Disease Research Program Cornelius Hopper Award #24RT-0035. We acknowledge Anna Epperson, PhD for her assistance with manuscript submission.
Dr. Prochaska has served as an expert witness in court cases against tobacco companies and has consulted for Pfizer, which makes smoking cessation medications. All other authors have no competing interests to disclose.