Writing a Quality paper
Revisiting the Hispanic Paradox in the United States: the role of
smoking
Andrew Fenelon
Population Studies and Training Center, Brown University, Brown University, 68 Waterman St.
Providence, RI 02912, (805) 886-6586
Andrew Fenelon: [email protected]
Abstract More than three decades of health disparities research in the United States has consistently found
lower adult mortality risks among Hispanics than their non-Hispanic white counterparts, despite
lower socioeconomic status among Hispanics. Explanations for the “Hispanic Paradox” include
selective migration and cultural factors, though neither has received convincing support. This
paper uses a large nationally representative survey of health and smoking behavior to examine
whether smoking can explain life expectancy advantage of Hispanics over US-born non-Hispanics
whites, with special attention to individuals of Mexican origin. It tests the selective migration
hypothesis using data on smoking among Mexico-to-US migrants in Mexico and the United
States. Both US-born and foreign-born Mexican-Americans exhibit a life expectancy advantage
vis-à-vis whites. All other Hispanics only show a longevity advantage among the foreign-born,
while those born in the United States are disadvantaged relative to whites. Smoking-attributable
mortality explains the majority of the advantage for Mexican-Americans, with more than 60% of
the gap deriving from lower rates of smoking among Mexican-Americans. There is no evidence of
selective migration with respect to smoking; Mexicans who migrate to the US smoke at similar
rates to Mexicans who remain in Mexico, with both groups smoking substantially less than non-
Hispanic whites in the US. The results suggest that more research is needed to effectively explain
the low burden of smoking among Mexican-Americans in the United States.
Keywords U.S.A; Hispanic paradox; cigarette smoking; life expectancy; migration; Mexican; selection
INTRODUCTION
More than three decades of health disparities research in the United States has consistently
found lower adult mortality risks among Hispanics than among their non-Hispanic white
counterparts (Elo et al., 2004; Hummer et al., 2000; Markides & Coreil, 1986). This occurs
despite lower average education and income and higher rates of poverty among Hispanics,
which gives rise to the term “Hispanic Paradox” (Markides & Eschbach, 2005; Palloni &
Arias, 2004). The phenomenon has been identified and thoroughly described using
nationally representative surveys, small-sample cohort studies, and vital statistics. The
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Author Manuscript
Soc Sci Med . Author manuscript; available in PMC 2014 April 01.
Published in final edited form as:
Soc Sci Med . 2013 April ; 82: 1–9. doi:10.1016/j.socscimed.2012.12.028.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Hispanic advantage in life expectancy is non-trivial, amounting to 2.5 years at birth
according to recently-released life tables by Hispanic origin produced by the National
Center for Health Statistics (Arias, 2010). Corresponding advantages are observed for many
chronic health conditions including cardiovascular disease, cancers, and chronic respiratory
diseases. The topic has received a large amount of attention in the literature, has been
investigated extensively, and a number of possible hypotheses have been offered. However,
despite its ubiquity, the Hispanic paradox has previously eluded a convincing explanation.
Examining Hispanics as a homogeneous group with a singular mortality experience is
problematic. The US Hispanic population has origins in many different countries with varied
social and economic circumstances and health profiles. The heterogeneity of mortality
experiences among subgroups within the Hispanic population is as large as that between
Hispanics and other race/ethnic groups in the US (Hummer et al., 2000), and recent research
contends that the Hispanic paradox is not a feature of all Hispanics, only of certain
subgroups. In addition to being the largest Hispanic subgroup, the Mexican population also
shows perhaps the most consistent mortality advantage relative to non-Hispanic whites
(Abraido-Lanza et al.,1999; Hummer et al., 2000; Sorlie et al.,1993). According to the 2010
Census, there were more than 30 million individuals of Mexican descent in the US, making
up more than 10% of the total population and nearly two-thirds of all Hispanics (US Census
Bureau, 2011). Indeed, the “Hispanic paradox” is largely a “Mexican paradox”, as Palloni
and Arias (2004) contend that the advantage exists primarily among Mexicans. Evidence for
the advantage among the next largest subgroups, Puerto Ricans and Cubans, is more mixed
(Abraido-Lanza et al., 1999; Sorlie et al., 1993). Puerto Ricans, especially those born in the
50 states, differ from other Hispanic subgroups in that they are often disadvantaged relative
to whites with respect to mortality (Hummer et al., 2000; Markides & Eschbach, 2005).
Related to the Hispanic paradox is the immigrant paradox, the tendency for foreign-born
populations to outlive the native-born despite lower socioeconomic status. A similar pattern
is observed within Hispanic populations, and some research asserts that the Hispanic
paradox exists only for the foreign-born (Palloni & Morenoff, 2001). Although other studies
find an advantage for US-born Hispanics, it is at best greatly diminished compared with that
of foreign-born Hispanics (Singh & Siahpush, 2002). Since nearly 60% of adult Hispanics
are foreign-born, it is inappropriate to consider Hispanic immigrants and US-born Hispanics
in combination, and explaining the Hispanic paradox necessarily requires attention to the
role of nativity.
This paper uses data from a nationally representative survey to examine the contribution of
cigarette smoking to the adult life expectancy advantage of Hispanics relative to US-born
non-Hispanic whites. The focus of the paper is the experience of foreign- and US-born
Mexican-Americans. In addition, the paper combines data from national surveys in Mexico
and the United States to test whether the findings with respect to smoking might reflect a
prominent explanation for the paradox: the
selective migration hypothesis . Individuals who
move from their origin country to the United States are likely to be in better health than
those who remain in the origin country on a number of dimensions that are relevant to the
Hispanic paradox (Abraido-Lanza et al., 1999).
EVIDENCE FOR THE HISPANIC MORTALITY ADVANTAGE The major sources of data on Hispanic mortality are US vital statistics and nationally
representative surveys. Studies using vital statistics suffer from issues related to differences
in the identification of Hispanic origin on death certificates and the census, and have the
potential to underestimate Hispanic mortality (Arias et al., 2008). Representative surveys
with prospective mortality follow-up partially solve this issue, since origin is self-reported
and respondents are matched to records in the National Death Index. Surveys also allow the
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NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript researcher to examine the Hispanic advantage across a variety of other covariates and to
examine the mortality of multiple Hispanic subgroups (Palloni & Arias, 2004). Although
evidence for the Hispanic paradox is abundant, empirical evidence for the most prominent
explanations is somewhat unconvincing. The two broad hypotheses for explaining the
paradox are
selective migration and culture .
Selective migration hypothesis Since most adult Hispanics in the United States are foreign born, any examination of the
Hispanic mortality experience must consider to what extent immigrants are a select group of
their origin country populations. If migrants differ significantly from non-migrants, our
estimates of the mortality of the foreign-born in the US may be biased. Selective migration
can refer to both in-migration of healthy individuals (healthy migrant effect) and out-
migration of unhealthy individuals (salmon bias). The former concerns the greater human
capital and health resources that may be necessary to undertake an international move, such
that we observe a highly select group of individuals from sending countries, potentially
offsetting the negative effects of their poor socioeconomic profile (Abraido-Lanza et al.,
1999). The latter suggests that foreign-born individuals in the United States may return to
their countries of origin when they become ill, leaving a healthier subset in the US (Palloni
& Ewbank, 2004).
The specific mechanisms through which selection operates are kept relatively vague in
conceptual formulations of the hypothesis (Palloni & Ewbank, 2004). Migrants may be
selected on aspects of underlying health or robustness, which are generally difficult to
measure, or on social characteristics that impact health, such as educational attainment or
wealth. Migrant selection may also operate through health-related behaviors if
characteristics such as poor diet, low physical activity, or cigarette smoking present greater
barriers to migration owing in part to the negative health effects of the behaviors
(Buttenheim et al., 2010). In general, direct investigation of health selection with respect to
immigration from Mexico to the US is lacking. The most comprehensive recent study was
by Rubalcava et al. (2008) who examined differences between Mexican immigrants to the
United States and Mexicans who remained in Mexico on several measures of health, and
found overall weak evidence for health-selective migration. No studies have considered
migrant selection on health behaviors.
Cultural hypothesis As with their mortality experience, it may be inappropriate to classify Hispanics as having a
singular consistent culture or assume that attitudes and practices are similar between or
within all Hispanic subgroups. Heterogeneity in the cultural practices and attitudes among
Hispanic subgroups is certainly large and attributing health outcomes of the Hispanic
population to cultural characteristics may ignore important variation (Rodriguez, 1995).
Still, certain aspects of shared culture may promote better health and prevent mortality
among specific Hispanic subgroups (Marin & Marin, 1991). Indeed, Mexican-Americans
living in enclaves with a high proportion of Mexican immigrants appear to retain Mexican
cultural traditions more effectively (Eschbach et al., 2004). These populations may benefit
from strong familial and friendship networks that provide a needed source of social support.
The positive effects of social support may be manifested in a number of ways including the
tendency to engage in healthier behaviors.
CIGARETTE SMOKING AND THE HISPANIC PARADOX Cigarette smoking may play a key role in the Hispanic mortality advantage for two reasons.
First, cigarette smoking has a strong negative impact on individual mortality and is the
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NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript single greatest cause of premature death in the United States (Mokdad et al., 2004). Smoking
is responsible for more than 20% of adult deaths among Americans (Preston et al., 2010).
Second, survey data indicate that Hispanics in the US have a relatively low prevalence of the
behavior. Hispanics who do smoke are also less likely to do so every day, smoke fewer
cigarettes per day, and have smoked for fewer years on average than non-Hispanic whites
(Siahpush et al., 2010). Non-Hispanic whites are more likely than Hispanics to smoke and
are likely to have higher amounts of accumulated physiological damage from a history of
heavy smoking (Bethel & Schenker, 2005). As this evidence has grown in recent years,
several studies have considered the relevance of smoking to the Hispanic paradox (Perez-
Stable et al., 2001). The Hispanic advantage is largest for causes of death that are strongly
associated with smoking including lung cancers, respiratory diseases, and ischemic heart
disease (Singh & Siahpush, 2002). Blue and Fenelon (2011) were the first to directly
examine the contribution of smoking to the Hispanic paradox. They used an indirect method
to estimate smoking-attributable mortality for all Hispanics and non-Hispanics whites using
vital statistics data from the year 2000. They found that smoking-related mortality was
responsible for 75% of the Hispanic advantage in life expectancy at age 50 for men and for
women (both slightly more than 2 years).
Their study did not account for differences by nativity and country of origin in mortality or
smoking experience among Hispanics. Much of the reason we observe such low prevalence
and intensity of smoking among Hispanics is the particularly light smoking of the Hispanic
immigrant population (Singh & Siahpush, 2002). Consistent with the immigrant health
advantage, evidence suggests that foreign-born Hispanics smoke less than their US-born
counterparts and significantly less than non-Hispanic whites. Mexican-Americans are the
largest subgroup of both foreign- and US-born Hispanics, and have substantial leverage in
determining the predominant smoking patterns of the Hispanic population as a whole.
Surveys indicate that Mexican-Americans smoke less than many other Hispanic subgroups
including Cubans and Puerto Ricans (Singh & Siahpush, 2002). Mexican-Americans also
appear to have exceptionally low cigarette consumption, with a large fraction of smokers in
this group identifying as “intermittent” or “occasional” rather than “daily” smokers
(Caraballo et al., 1998).
DATA This paper uses data from the National Health Interview Survey Linked-Mortality Files
(NHIS-LMF), which are obtained through the Integrated Health Interview Series (IHIS,
2010). NHIS collects detailed demographic, behavioral, and health information in annual
cross-sectional samples. Respondents are linked to US death records in the National Death
Index through the end of 2006. Annual surveys are pooled for the years 1990 – 2004,
including only individuals aged 35 or older and for whom smoking status was identified.
Age 35 is chosen as a cutoff because few smoking-related deaths occur prior to age 35 and
because the Hispanic advantage is concentrated in the adult age range (Markides &
Eschbach, 2005). The final sample includes a total of 155,173 women and 119,138 men and
35,224 deaths. Observations are weighted using supplement-specific annual person weights
for survey years 1990 – 1995 and mortality sample adult weights for 1997 – 2004. The study
was exempt from human subjects review since all data are publicly available and do not
contain individual identifiers.
Smoking status is measured through a series of questions and respondents are classified into
six groups according to current and past smoking behavior and current daily cigarette
consumption. Respondents who have smoked fewer than 100 cigarettes in their entire lives
are classified as “never smokers”. Respondents who report having smoked at least 100
cigarettes but who answer “no” to the question “Do you currently smoke cigarettes every Fenelon Page 4
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NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript day or some days?” are coded as “former smokers”. The definition of “every day or some
days” is left up to the respondent. To account for increased mortality risk associated with
greater cigarette consumption, current smokers are also classified by number of cigarettes
smoked per day: current very light smoker (fewer than 10 cigarettes per day), light smoker
(10–19 per day), medium smoker (20–29 per day), and heavy smoker (30+ per day).
Individuals are categorized into 5 race/ethnic groups based on nativity and Hispanic origin:
1) US-born non-Hispanic whites, who serve as the majority comparison group for each
Hispanic subgroup, 2) US-born Mexican-Americans, individuals specifically identifying as
being of Mexican origin born in the United States, 3) US-born other Hispanics, individuals
who are of Hispanic but not Mexican origin and born in the United States, 4) foreign-born
Mexican-Americans, Mexican origin individuals born outside the United States, and 5)
foreign-born other Hispanics. Small sample sizes precluded the analysis of smoking with
respect to more detailed countries of origin among Hispanics.
METHODS
Statistical model Loglinear hazard regression models are used to estimate all-cause death rates and the impact
of smoking by race/ethnic group (Rogers et al. 2005). The models predict the all-cause
mortality hazard as a function of 5-year age groups (35–39, 40–44,…,85+), race/ethnic
group, and smoking status. Models are stratified by sex and include an interaction between
the “former smoker” category and race/ethnic group in order to account for race/ethnic
differences in daily cigarette consumption among former smokers. If white former smokers
smoked more heavily before quitting, they may experience a higher relative mortality risk of
former smoking than lighter-smoking Hispanic subgroups. Individuals contribute risk
exposure each year between interview (or age 35 for those younger at baseline) and death or
censoring. Censoring occurs for individuals who are alive as of the end of 2006.
Life expectancy in the presence and absence of smoking Mortality attributable to cigarette smoking in each race/ethnic group is calculated using a
conventional attributable-risk approach. This method estimates the proportion of deaths in
each group that would not occur if smokers experienced no excess mortality relative to
never-smokers. The method takes into account both the proportion of individuals in each
smoking status category as well as the estimated relative mortality risk of each smoking
status compared with never smokers based on the hazard model described above. Smoking-
attributable mortality is calculated for men and women by 5-year age group and race/ethnic
group. These values allow us to examine life expectancy in the presence and absence of
smoking. Life expectancy at age 35 is estimated using standard life table methods (Preston
et al., 2001). Life expectancies for each race/ethnic group in the presence of smoking (
e35 )
are calculated using predicted death rates from observed covariate values, while
corresponding life expectancies in the absence of smoking (
) are calculated using death
rates with smoking-related mortality removed. The change in the life expectancy gap after
the removal of smoking represents the portion of the advantage that is attributable to
smoking. The contribution is calculated as
where H e 35 and We 35 are life expectancies at age 35 for the Hispanic subgroup and US-born
non-Hispanic whites, respectively.
and are the same values calculated in the
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NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript absence of smoking. The first term in the equation refers to the life expectancy advantage (in
years) for the Hispanic subgroup in the presence of smoking and the second term is the
advantage in the absence of smoking.
Standard errors for attributable-risk fractions and the contribution of smoking are estimated
by simulated resampling based on regression parameter uncertainty. 1,000 sets of age-
specific death rates are simulated by allowing these death rates to vary within the regression-
predicted parameter variance determined by the variance-covariance matrix of the hazard
regression model. These sets of death rates produce a simulated sample of attributable-
fractions and contributions of smoking from which it is possible to calculate standard errors.
95% confidence intervals are reported in the results below.
Testing the selective migration hypothesis In order to test the selective migration hypothesis with respect to smoking, it is necessary to
compare smoking prevalence of migrants and non-migrants in Mexico prior to migration.
NHIS data are combined with data from the Mexican Family-Life Survey (MxFLS), a panel
survey in Mexico that completes follow-up interviews for all respondents irrespective of
changes in residential location, which includes more than 800 individuals who migrated to
the United States between 2002 and 2005 (Rubalcava & Teruel, 2008). Information on
cigarette smoking comes from respondent self-reports of current and past behavior, and is
comparable to that in the NHIS. Among individuals ages 18–39, logistic regression is used
to predict the probability of being a current smoker for five groups based on place of birth
and migrant status. Two groups come from MxFLS: 1) Mexican non-migrants who remain
in Mexico between 2002 and 2005, and 2) Mexico-to-US migrants who enter the United
States during this period. Three groups come from the NHIS: 3) Mexican immigrants who
arrived in the US within the past 5 years, 4) US-born Mexican-Americans, and 5) US-born
non-Hispanic whites. If selective migration is operating, Mexico-to-US migrants and
Mexican immigrants in the US should be less likely to smoke than non-migrants in Mexico.
RESULTS Consistent with previous research, this study found that Hispanics significantly outlived US-
born non-Hispanic whites at age 35, though there were differences by nativity and country
of origin (Table 1). Among US-born Hispanics, only Mexican-Americans experienced an
advantage over whites (1.9 years among women, 1 year among men). US-born other
Hispanics were at a substantial disadvantage, trailing whites by 1.5 years among women.
Foreign-born Mexican-Americans had a large life expectancy advantage, outliving whites by
3 years among women and 2.1 years among men. The advantage was fairly similar for
Foreign-born other Hispanics.
Data on smoking status (Table 2) suggested that Mexican-Americans have a lower burden of
smoking than whites. Among men, the major difference between whites and Mexican-
Americans in the impact of smoking was in the prevalence of medium or heavy current
smoking. While more than 70% of white men smokers consumed at least one pack (20
cigarettes) per day, only 33% of US-born and 20% of foreign-born Mexican-Americans men
did. Among women, whites also smoked more heavily than Mexican-Americans. Nearly
one-fifth of white women were current smokers compared with 13% of US-born and only
8% of foreign-born Mexican-American women. Nearly 60% of white women smokers
smoked a pack or more per day, compared to only 23% of US-born Mexican-American
women and 11% of foreign-born Mexican-American women. While US-born other Hispanic
men and women were slightly
more likely to smoke than whites, foreign-born other
Hispanics showed a substantially lower prevalence and daily cigarette consumption.
Fenelon Page 6
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NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Estimated regression results (hazard ratios) are presented in Table 3 by sex. Model 1
includes only age and race/ethnic group, and Model 2 adds smoking status variables. Model
1 indicated that Mexican-Americans and foreign-born other Hispanics experienced lower
mortality risks than non-Hispanic whites. The inclusion of smoking status in Model 2
attenuated these differences. Each smoking status experienced higher mortality than never
smokers, and the risk increased with greater consumption. Light smokers had 80%–100%
higher risk of death while heavy smokers had a risk three times that of never smokers.
Interactions between the former smoker category and race/ethnic group were significant for
foreign-born Mexican-Americans and other Hispanics. The coefficients indicated that the
mortality risk associated with being a former smoker was lower for foreign-born Hispanic
subgroups than for whites, presumably reflecting higher former cigarette consumption
among whites.
The smoking data in Table 2 along with the regression coefficients in Table 3 were used to
predict the fraction of deaths attributable to smoking by sex for each race/ethnic group,
shown in Figure 1. There was substantial variation among race/ethnic groups in the
mortality burden of smoking. 28% (95% CI: 26%–30%) of deaths among white men and
21% (19%–22%) among white women were due to smoking. Comparatively, attributable-
fractions for US-born Mexican-American men and women were 26% and 15%, respectively.
Attributable risk for foreign-born Mexican-Americans was lower still, just 16% (12%–19%)
for men and 10% (9%–12%) for women. US-born other Hispanic women had substantially
higher smoking-attributable mortality (24%) than whites, and other Hispanic men had levels
similar to those of whites. Foreign-born other Hispanics had relatively low smoking-
attributable mortality, 7% among women and 23% among men.
Removing smoking-attributable mortality produced estimates of the contribution of smoking
to the life expectancy advantage of each Hispanic subgroup. These are shown in Figure 2a
for women and 2b for men. Smoking was a major factor explaining the advantage, though
the absolute contribution differed significantly by subgroup. Smoking explained 1.1 years
(60%) of the advantage of US-born Mexican-American women and 1.9 years (61%) among
the foreign-born. Among Mexican-American men, it explained 0.7 years (89%) for the US-
born and 1.3 years (61%) for the foreign-born. Smoking also explained a substantial fraction
of the advantage of foreign-born other Hispanics, 1.9 years among men and 1 year among
women. Among US-born other Hispanic women, smoking appeared to be partially
responsible for their life expectancy disadvantage, which would decrease by 0.7 years (46%)
in the absence of smoking. Differences in smoking also contributed to the life expectancy
advantage of foreign-born Mexican-Americans over the US-born. Among women, smoking
explained 64% of this difference and among men 44%.
Testing the selective migration hypothesis Data from MxFLS provide smoking status information on 315 Mexico-to-US migrants
collected in 2002 prior to migration. Figure 3 compares smoking behavior of this group to
non-migrants in order to test the selective migration hypothesis. Panel (a) shows the
prevalence of current smoking for women by migrant status. Overall, there was no evidence
of selective migration with respect to smoking status. Mexico-to-US migrants and non-
migrants showed very similar prevalence of smoking among individuals aged 18–39 (23%
among men, 6–7% among women). The prevalence of smoking among recent Mexican
immigrants in the US was also very similar to the figures in Mexico, 25% among men and
4% among women, suggesting that low rates of smoking in Mexico were maintained among
Mexicans in the United States. US-born Mexican-Americans showed higher prevalence than
Mexican-born groups among women but not among men. US-born whites showed the
highest prevalence among both men and women, consistent with the finding that smoking
contributes to the life expectancy advantage for Mexican-born individuals in the US. Fenelon Page 7
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NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Social gradients in health and the Hispanic advantageAn important aspect of the Hispanic advantage is the differential relationship between
socioeconomic status (SES) and mortality among Hispanics as compared to whites. Among
whites, the socioeconomic gradient is strong, while the corresponding gradient for Hispanic
populations is considerably less steep, with smaller differences in mortality risk by SES. As
a result, the Hispanic mortality advantage is concentrated in the lower end of the
socioeconomic spectrum (Turra & Goldman, 2007). This section examines the contribution
of smoking to the advantage of US-born and foreign-born Mexican-Americans in two
education categories: high school education or less (low), and college graduate or more
(high). Individuals with some college were excluded. Both Mexican-American subgroups
exhibited weaker education gradients than whites, and their life expectancy advantages were
substantially larger in the low education group (Figure 4). Foreign-born Mexican-American
women outlived whites by 3.5 years in the low education group and only 1.1 years in the
high education group. Corresponding advantages for men were 4.5 years and 0.6 years. The
life expectancy advantage of US-born Mexican-Americans was driven by the experience of
those with low education; whites had a 0.7-year life expectancy advantage among men and a
1.3-year advantage among women among the highly educated. Likewise, the contribution of
smoking was greater in the low education group compared to the high education group, 1.9
years compared to 0.6 years for foreign-born Mexican-American women, and 1 year
compared to 0.5 years for the US-born. The pattern was similar for men. Overall, smoking
explained 54% of the difference in the education gradient (size of the high-low education
gap in life expectancy) between whites and foreign-born Mexican-American among women
and 6% among men.
The results were also similar when the hazard model included a simple control for
education. Table 4 presents the contribution of smoking based on estimates from a model
including a dummy variable for educational category. The similarity of these results to those
of the original model suggested that education did not significantly confound the
relationship between smoking and mortality. Although education was correlated with both
the likelihood of smoking and with mortality risk, the inclusion of education in the models
had little effect on the estimated coefficients for smoking, consistent with evidence on
confounding in the smoking-mortality relationship (Thun et al., 2000). Adjusting for
education did not impact the conclusion that smoking explains a majority of the Hispanic
advantage.
Discussion This study examines the impact of cigarette smoking on the mortality advantage of
Hispanics over non-Hispanic whites in the United States. The results confirm that the
Hispanic advantage is not consistent across all Hispanic subgroups. Mexican-Americans,
both foreign- and US-born, enjoy a significant life expectancy advantage over whites. On
the other hand, other US-born Hispanics (primarily Puerto Ricans) are disadvantaged. The
differences observed and between US-born non-Hispanic whites and foreign-born Mexican-
Americans are similar to those in official US life tables (Arias, 2010). The principal
contribution of this study is establishing that low smoking-related mortality among
Hispanics is the primary reason for their favorable mortality experience vis-à-vis non-
Hispanic whites. Although this finding mainly refers to Mexican-Americans, it is also true
of foreign-born other Hispanics. The first direct treatment of the issue indicated that low
rates of lung cancer among Hispanics suggests that smoking explains the majority of their
life expectancy advantage over non-Hispanic whites (Blue & Fenelon, 2011). The current
study improves on this analysis in two ways. First, it establishes a better connection of the
findings to real data on cigarette smoking, showing indeed that smoking is less common
among Hispanics than non-Hispanic whites, and that this translates into a substantially lower Fenelon Page 8
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NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript mortality burden of smoking. Second, examining the process by nativity and specifically
among Mexican-Americans reveals meaningful variation within the Hispanic population
both in mortality and in the impact of smoking. The current study also demonstrates that the
smoking explanation is consistent with the educational pattern of the Hispanic advantage. A
relatively high burden of smoking among less educated whites partially helps to explain why
the life expectancy advantage for Mexican-Americans is concentrated among those with low
SES. This finding is consistent with evidence that social gradients in health in rural Mexico
are quite flat and that Mexican immigrants import social patterns of health and health
behaviors (Buttenheim et al., 2010; Smith & Goldman, 2007).
Another important contribution is a direct test of the selective migration hypothesis in
explaining the low smoking prevalence among Mexican immigrants in the United States.
This is the first examination of selective migration with respect to cigarette smoking. The
results reveal no evidence of the selective migration of non-smokers from Mexico. On the
contrary, Mexican individuals who migrate to the United States are about as likely to smoke
as their counterparts who remain in Mexico, and smoke at comparable rates after arriving in
the US. Cigarette smoking itself does not appear to present a barrier to migration, which is
consistent with previous research documenting that health selection among Mexican
immigrants is relatively weak, perhaps due to geographic proximity (Akresh & Frank, 2008;
Rubalcava et al., 2008).
The finding that Mexican-born individuals in both Mexico and the United States smoke at
very similar rates may support the cultural hypothesis, although NHIS data are insufficient
to test the particular pathways through which Mexican culture might discourage smoking.
Cultural norms in Mexico tend to stress the role of the group in health and social
considerations (Gallo et al., 2009). The “allocentric” perspective places the needs of the
group above those of the individual, which may eliminate some individual health behavior
decision-making (Almeida et al., 2009). Alternatively, comparatively low smoking among
Mexicans may not reflect cultural considerations at all. Although rarely considered in
studies on the Hispanic paradox, an additional explanation concerns the relatively high cost
of cigarettes relative to income in Mexico. Efforts by the tobacco industry in Mexico have
been particularly potent, including attempts by cigarette companies to limit regulations to
less strict versions of the World Health Organization recommendations (Samet et al., 2006).
Despite widespread salience of the tobacco industry, smoking may be kept low partially due
to economic considerations of cigarette pricing. In Mexico, individuals in disadvantaged
communities often exchange single cigarettes. The “Sachet economy”, buying less more
often, has widespread effects on the consumption of non-necessities (Singh et al., 2009).
This model is highly prevalent as a cost containment method in Mexico, and smokers who
purchase single cigarettes often smoke less than they would if cigarettes were available only
in packs (Thrasher et al., 2009). If we assume that low smoking among Mexicans reflects an
exclusively behavioral-cultural orientation rather than economic considerations, we may
incorrectly conclude that smoking will remain low as incomes rise in Mexico.
The principal limitation of this study is the inability to account for return migration. Even if
return migrants are no less healthy than those who remain in the US, Hispanic mortality will
still be biased because deaths that occur abroad are unobserved in US vital registration. As
Palloni and Arias (2004) indicate, this will lead to an increase in the size of the advantage at
older ages as return migration increases. Despite findings that salmon bias explains only
very little of the Hispanic advantage (Abraido-Lanza et al., 1999; Turra & Elo, 2008), it
remains an issue that the present data cannot completely address and is the toughest
challenge to the Hispanic paradox (Markides & Eschbach, 2005). To fully address the
challenge of salmon bias would require multinational data capturing the mortality Fenelon Page 9
Soc Sci Med . Author manuscript; available in PMC 2014 April 01.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript experience of foreign-born individuals outside the United States. Such data are currently
unavailable for most purposes.
Conclusion The Hispanic paradox represents an important situation in social science research in which a
group with lower socioeconomic status outperforms the high-status majority group with
respect to health outcomes. Explaining the Hispanic paradox thus improves our knowledge
of the factors that mediate the relationship between socioeconomic status and health, in
addition to providing a fruitful description of the mortality experience of Hispanics. This
study also provides strong evidence that the favorable health and mortality experience of
Mexican immigrants in the United States is not a consequence of selective migration. This
finding is important in itself, but it should also inform a future research agenda on the
factors that mediate the relationship between socioeconomic status and health for other
immigrant groups in the United States. Studies examining better-than-expected health
outcomes among immigrant populations should not assume that these findings are being
driven by health-selective migration, and should look deeper into social, economic, and
behavioral characteristics of the migrant populations, both in their origin countries and in the
United States. As the results of the current study show, testing for selective migration
requires measuring health (behaviors) among those who migrate as well as those who do
not.
Recognizing that smoking is the primary proximate reason for the life expectancy advantage
of Mexican-Americans is important but is less policy relevant before we understand the
underlying reasons for extant disparities in smoking. The results of this study confirm that
migrant selection effects are not responsible for low smoking among Mexicans. Whatever
does keep smoking low in Mexico, it appears to be retained more effectively in the United
States by the immigrants themselves than by their children. Foreign-born Mexican-
Americans live one and a half years longer at age 35 than Mexican-Americans born in the
United States. The gap among other Hispanic subgroups is even larger, 3–4 years. Among
Hispanics, there is evidence that linguistic and cultural assimilation is accompanied by
behavioral assimilation (Acevedo-Garcia et al., 2005); health behaviors converge to the
mainstream norm with greater exposure to US cultural and social norms, and this includes
heavier smoking among US-born Hispanics than their parents’ generation (Gordon-Larsen et
al., 2003). This realization presents an opportunity for policymakers to improve the health of
U.S. populations. Policy interventions designed to reduce the impact of smoking should
prioritize research aimed at understanding the smoking behavior of Mexican immigrants in
the United States. The specific factors that keep smoking low among Mexican-born
populations might also be generalized to benefit other immigrant and non-immigrant
populations in the United States that suffer a high burden of smoking. As knowledge of the
role of smoking in population health grows, it will become increasingly important for
policymakers to identify paths to reducing its impact, particularly in high-risk populations.
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NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Appendix: Sensitivity and RobustnessIn order to examine the sensitivity of the results to the attributable-risk method and model
selection, I perform several robustness checks. To investigate the sensitivity of the results to
this choice of attributable-risk method, I also estimate attributable-risk using an indirect
method developed by Preston et al. (2010) and refined by the analysis in Fenelon and
Preston (2012). This method uses the lung cancer death rate as an indicator of the
cumulative damage from smoking in a population. The approach is supported by evidence
that smoking is responsible for the vast majority of lung cancer deaths and that differences
in lung cancer mortality across populations and over time largely reflect differences in
smoking (Peto et al., 1992). I estimate age-specific lung cancer death rates by race/ethnic
group using hazard regression. The regression predicts the hazard of lung cancer death,
treating deaths for all other causes of death as censoring. These rates are used to calculate
attributable-risk based on coefficients estimated in Fenelon and Preston (2012). Results
using this attributable-risk method are presented in Table A1. The results indicate that the
main findings are robust to alternative attributable risk methods. Although this produced a
slight difference in the estimated contribution of smoking, the substantive conclusion
remained unchanged. Table A1
Contribution of Smoking using alternative attributable risk method: Life expectancy at age
50
Life Expectancy AdvantageAdvantage Explained by Smoking% of advantageattributable to smokingWomen US-born Mexican-American 1.89 (1.8 – 2.1)1.70 (1.4 – 2.0)90.10% US-born other Hispanic −1.90 (−2.2 – −1.6)−0.89 (−1.2 – −0.6)46.84% Foreign-born Mexican-American 2.73 (2.6 – 2.9)1.60 (1.3 – 1.9)58.60% Foreign-born other Hispanic 2.84 (2.6 – 3.1)1.74 (1.5 – 2.0)61.10% Men US-born Mexican-American 0.82 (0.5 – 1.2)0.87 (0.6 – 2.1)106.10% 1 US-born other Hispanic −0.16 (−0.5 – 0.2)0.23 (−0.2 – 0.5)−143.8% 2 Foreign-born Mexican-American 1.99 (1.7 – 2.3)1.54 (1.3 – 1.8)77.40% Foreign-born other Hispanic 2.70 (2.4 – 3.0)1.68 (1.4 – 2.0)62.20%
Notes: Life expectancy advantages are in years at age 50. Smoking-attributable mortality and contribution of smoking
estimated using indirect method developed in Preston et al. (2010) and refined in Fenelon and Preston (2012). 95%
confidence intervals in parentheses.
1Contribution greater than 100% indicates that, in the absence of smoking, US-born Mexican-American men would be
disadvantaged relative to non-Hispanic white men.
2This percentage contribution is not statistically distinguishable from zero.
Fenelon Page 13
Soc Sci Med . Author manuscript; available in PMC 2014 April 01.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript ·Smoking contributes 1.9 years to the advantage of foreign-born Mexican-
American women and 1.3 to the advantage of men compared with non-Hispanic
whites, 60% of the total advantage
· The contribution of smoking is larger for foreign-born Hispanics than for US-
born Hispanics
· Smoking explains 50% of the difference between non-Hispanic whites and
Mexican-Americans in the size of the educational gap in life expectancy
· Selective migration does not explain favorable smoking behavior among
Mexicans in the US
Fenelon Page 14
Soc Sci Med . Author manuscript; available in PMC 2014 April 01.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Figure 1.
Percent of deaths attributable to smoking by race/ethnic group ages 35 and above. Estimated
using hazard regression by comparing the predicted mortality for each race/ethnic using
observed smoking status distribution to the predicted mortality for never smokers. Error bars
indicate 95% confidence intervals of attributable-risk.
Source: Author’s calculations from National Health Interview Survey pooled smoking
supplements 1990 – 2004.
Fenelon Page 15
Soc Sci Med . Author manuscript; available in PMC 2014 April 01.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Figure 2.
Contribution of smoking to the life expectancy advantage of each Hispanic subgroup over
US-born non-Hispanic whites at age 35. The black bar refers to the contribution of smoking
to the advantage of each subgroup. The grey bar refers to the contribution of other factors
and represents the size of the advantage in the absence of smoking. Error bars indicate 95%
confidence intervals for the contribution of smoking.
Source: Author’s calculation using National Health Interview Survey pooled smoking
supplements 1990 – 2004.
Fenelon Page 16
Soc Sci Med . Author manuscript; available in PMC 2014 April 01.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Figure 3.
Current smoking prevalence by migrant status among individuals ages 18 – 39 Two groups
on the left of the black line come from the Mexican Family Life Survey. Mexico to US
migrants enter to the United States between 2002 and 2005, while non-migrants remain in
Mexico. The three groups on the right of the black line come from the National Health
Interview Survey 2002 – 2005.
Source: Authors calculations using logistic regression on pooled NHIS-MxFLS sample.
Fenelon Page 17
Soc Sci Med . Author manuscript; available in PMC 2014 April 01.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Figure 4.
Contribution of smoking to the life expectancy advantage of Mexican-American subgroups
over US-born non-Hispanic whites at age 35 for women by level of education. The black bar
refers to the contribution of smoking to the advantage of each subgroup. The grey bar refers
to the contribution of other factors and represents the size of the advantage in the absence of
smoking.
Source: Author’s calculation using National Health Interview Survey pooled smoking
supplements 1990 – 2004.
Fenelon Page 18
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NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript FenelonPage 19 Table 1
Estimated remaining life expectancy in years at age 35 by race/ethnic group and sex WomenMen Life ExpectancyAdvantage 1Life ExpectancyAdvantage US-born non-Hispanic white47.60 (47.3 – 47.9) -- 41.67 (41.5 – 41.9) -- US-born Mexican-American49.52 (48.9 – 50.1)1.92 (1.8 – 2.1)42.48 (42.5 – 43.6)0.81 (0.5 – 1.2)US-born other Hispanic46.03 (45.0 – 45.9)−1.57 (−1.2 – −1.9)41.27 (40.8 – 41.7)−0.40 (−0.8 – 0.0)Foreign-born Mexican-American50.71 (50.4 – 51.0)3.11 (3.0 – 3.3)43.81 (43.2 – 44.4)2.14 (1.8 – 2.5)Foreign-born other Hispanic50.58 (49.8 – 50.4)2.98 (2.8 – 3.3)44.39 (44.0 – 44.8)2.72 (2.3 – 3.1)
Notes: Estimated with hazard regression using NHIS pooled samples 1990 – 2004. 95% confidence intervals in parentheses. Mexican-\
Americans
respond as being of Mexican origin. Other Hispanics are all Hispanics not of Mexican origin
1In years at age 35 compared with US-born non-Hispanic whites
Soc Sci Med . Author manuscript; available in PMC 2014 April 01. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript FenelonPage 20 Table 2
Baseline smoking status by race/ethnic group ages 35 and above NNever SmokerFormer SmokerCurrent SmokerCurrent Very Light SmokerCurrent LightCurrent MediumCurrent HeavyWomen Non-Hispanic white131,949 54.7%26.518.8 2.6 5.27.63.3 US-born Mexican-American6,19667.6%19.213.2 6.0 4.22.40.7 US-born other Hispanic3,47856.8%21.222.0 8.8 6.25.31.7 Foreign-born Mexican-American6,31881.2%11.17.7 5.6 1.20.80.1 Foreign-born other Hispanic7,23274.9%13.711.4 5.8 3.02.20.4 Men Non-Hispanic white101,861 37.0%41.921.1 2.0 3.88.46.9 US-born Mexican-American4,49143.0%35.821.2 8.3 5.85.21.9 US-born other Hispanic2,41944.2%31.524.3 7.1 6.77.43.1 Foreign-born Mexican-American5,54548.8%31.919.3 10.8 4.93.20.6 Foreign-born other Hispanic4,82251.3%28.919.8 7.7 5.25.21.7
Notes: Cigarette consumption categories: very light = 0–9 cigarettes per day; light = 10–19 per day; medium = 20–29; heavy = 30+\
. All values are age-standardized for comparison across race/ethnic
groups.
Source: National Health Interview Survey pooled smoking supplements 1990 – 2004.
Soc Sci Med . Author manuscript; available in PMC 2014 April 01. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript FenelonPage 21 Table 3
Estimated impact of smoking on mortality: Hazard regression WomenMen Age Model 1Model 2Model 1Model 2 35–39 (ref.) -------- 40–441.8 (1.4 – 2.2)1.8 (1.2 – 2.3)1.8 (1.5 – 2.2)1.7 (1.3 – 2.2) 45–492.7 (2.2 – 3.3)2.7 (1.9 – 3.5)2.8 (2.3 – 3.5)2.6 (2.0 – 3.3) 50–544.1 (3.4 – 5.0)4.1 (3.0 – 5.2)4.3 (3.5 – 5.2)3.9 (3.0 – 5.0) 55–596.6 (5.5 – 7.9)6.5 (4.6 – 8.3)6.7 (5.5 – 8.1)6.1 (4.8 – 7.8) 60–6410.7 (9.0 – 12.8)10.7 (7.9 – 13.8)10.8 (9.0 – 13.1)9.8 (7.7 – 12.5) 65–6916.7 (14.0 – 19.8)17.3 (13.3 – 22.8)17.2 (14.3 – 20.6)15.1 (11.8 – 19.2) 70–7425.7 (21.6 – 30.3)27.6 (20.5 – 35.6)26.3 (22.0 – 31.4)23.5 (18.5 – 29.9) 75–7940.9 (34.4 – 48.1)45.8 (34.8 – 60.1)42.2 (35.4 – 50.4)39.2 (30.8 – 49.8) 80–8467.1 (57 – 79)78.9 (59 – 103)68.6 (58 – 82)66.7 (53 – 85) 85+138.6 (117 – 163)172.4 (130 – 229)142.2 (119 – 169)146.9 (116 – 187)race/ethnic group US-born white (ref.) -------- US-born Mexican0.94 (0.88 – 1.00)0.99 (0.91 – 1.09)0.95 (0.88 – 1.03)1.01 (0.92 – 1.10) US-born other1.16 (1.02 – 1.31)1.12 (0.97 – 1.30)1.07 (0.98 – 1.17)1.15 (1.01 – 1.29) Foreign-born Mexican0.80 (0.74 – 0.86)0.96 (0.89 – 1.02)0.85 (0.77 – 0.91)0.99 (0.89 – 1.10) Foreign-born other0.77 (0.70 – 0.84)0.88 (0.80 – 0.98)0.81 (0.71 – 0.93)0.85 (0.73 – 0.96)Smoking Never smoker (ref.) ---- Former smoker1.36 (1.31 – 1.40)1.34 (1.30 – 1.38) Current (0–9 cigs per day)1.80 (1.66 – 1.95)2.00 (1.82 – 2.20) Current (10–19)2.10 (1.95 – 2.26)2.11 (1.98 – 2.25) Current (20–29)2.51 (2.36 – 2.66)2.51 (2.38 – 2.63) Current (30+)3.13 (2.88 – 3.40)3.13 (2.88 – 3.39)Smoking Interactions Former x US-born Mex.1.05 (0.96 – 1.13)0.86 (0.70 – 1.08) Former x US-born other0.93 (0.85 – 1.00)1.07 (0.87 – 1.30) Former x For.-born Mex.1.15 (0.87 – 1.52)1.11 (0.97 – 1.24) Former x For.-born other.0.78 (0.60 – 0.97)0.83 (0.73 – 0.97) Constant 0.0008570.0006210.001720.00116 N 155,173155,173119,138119,138
Notes: Estimated using hazard regression on data from NHIS smoking supplements 1990 – 2004. Hazard ratios shown. 95% confidence \
intervals in
parentheses. Interactions reflect differences in the mortality risk of former smoking by race/ethnic group. Model 1 includes age\
and race/ethnic
group. Model 2 adds coefficients for smoking status.
Soc Sci Med . Author manuscript; available in PMC 2014 April 01. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript FenelonPage 22 Table 4
Contribution of Smoking to life expectancy advantage at age 35 based on coefficients adjusted for education Life Expectancy AdvantageAdvantage in the Absence of Smoking% of advantage attributable to smokingWomen US-born Mexican-American 1.921.3368.20% US-born other Hispanic −1.57−0.7849.68% 1 Foreign-born Mexican-American 3.111.6753.71% Foreign-born other Hispanic 2.981.4749.33% Men US-born Mexican-American 0.810.5770.10% US-born other Hispanic −0.4−0.1127.51% 1 Foreign-born Mexican-American 2.141.2960.28% Foreign-born other Hispanic 2.721.8969.49%
Notes: Life expectancy advantages are in years at age 35. Smoking-attributable mortality and contribution of smoking estimated u\
sing a standard
attributable-risk method. Coefficients for smoking status are adjusted for education: high school or less, and college graduate \
or more.
1For US-born other Hispanics, higher smoking attributable mortality partially explains their mortality disadvantage relative to whites.
Soc Sci Med . Author manuscript; available in PMC 2014 April 01.
