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Journal of Health Communication

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Translation and Adaptation of Smoking RelapsePrevention Materials for Pregnant and Postpartum Hispanic Women
Vani Nath Simmons , Ligia M. Cruz , Thomas H. Brandon Gwendolyn P. Quinn
a a a b c a

&

Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
b

Department of Global Health, College of Public Health, University of South Florida, Tampa, Florida, USA
c

Departments of Psychology and Oncologic Services, University of South Florida, Tampa, Florida, USA Available online: 29 Nov 2010

To cite this article: Vani Nath Simmons, Ligia M. Cruz, Thomas H. Brandon & Gwendolyn P. Quinn (2010): Translation and Adaptation of Smoking RelapsePrevention Materials for Pregnant and Postpartum Hispanic Women, Journal of Health Communication, 16:1, 90-107 To link to this article: http://dx.doi.org/10.1080/10810730.2010.529492

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Journal of Health Communication, 16:90107, 2011 Copyright # Taylor & Francis Group, LLC ISSN: 1081-0730 print=1087-0415 online DOI: 10.1080/10810730.2010.529492

Translation and Adaptation of Smoking RelapsePrevention Materials for Pregnant and Postpartum Hispanic Women
VANI NATH SIMMONS
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Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA

LIGIA M. CRUZ
Department of Global Health, College of Public Health, University of South Florida, Tampa, Florida, USA

THOMAS H. BRANDON
Departments of Psychology and Oncologic Services, University of South Florida, Tampa, Florida, USA and the Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA

GWENDOLYN P. QUINN
Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
Quitting smoking is one of the most important behavior changes a pregnant woman can make, with health benefits extending beyond pregnancy for the woman and her child. Increasing numbers of pregnant women are quitting smoking; however, the majority resume smoking later in their pregnancy or shortly after giving birth. Previous research has demonstrated the efficacy of self-help smoking relapseprevention booklets; however, there is a dearth of materials available in Spanish for Hispanic smokers. The goal of the present study was to translate and adapt existing, theoretically based, smoking relapseprevention materials for pregnant and postpartum Hispanic women. This article describes the transcreation approach used to ensure the Forever Free for Baby and Me booklets were linguistically and culturally relevant for the heterogeneous populations of Hispanic women. The authors conducted multistage formative research to adapt the booklets and modify vignettes and graphics. Compared with previous research conducted with pregnant non-Hispanic women, results revealed the following: (a) a lack of association or concern about smoking and weight gain, (b) the importance of family approval of behavior, and (c) stress related to difficulties surrounding the immigration experience. The

This research was supported by a grant from the March of Dimes, Florida Chapter. Address correspondence to Vani Nath Simmons, Tobacco Research and Intervention Program, H. Lee Moffitt Cancer Center and Research Institute, 4115 E. Fowler Avenue, Tampa, FL 33617, USA. E-mail: vani.simmons@moffitt.org

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authors qualitative findings confirm and extend past research that has suggested ways to enhance the cultural relevance and acceptability of a health intervention.

Quitting smoking is one of the most important behavior changes a pregnant woman can make. Smoking during pregnancy is related to multiple adverse maternal conditions and pregnancy outcomes including placenta previa, stillbirth, fetal growth restriction, and preterm birth (Centers for Disease Control and Prevention, 2004; Cnattingius, 2004). The harmful effects of smoking extend beyond pregnancy. Secondhand smoke is related to an increased risk of sudden infant death syndrome, ear infections, asthma, and behavioral problems (Brook, Brook, & Whiteman, 2000; Gilliland, Li, & Peters, 2001). Heightened public awareness about the effects of smoking on pregnancy has resulted in a greater number of pregnant women quitting smoking. Unfortunately, the majority of women resume smoking later in their pregnancy or within 3 months of having given birth (Fingerhut, Kleinman, & Kendrick, 1990; Ockene, 1993). One study reports smoking relapse rates as high as 7085% among pregnant women who quit smoking at some point during their pregnancy (Fang et al., 2004). Smoking relapse can be attributed to several unique pregnancyrelated factors, such as increased stress as a result of caring for a newborn, desire to return to their prepregnancy form, and hormonal changes that may lead to depression (Ripley-Moffitt et al., 2008). Moreover, at the point of cessation, many women may be highly motivated to quit smoking to protect the health of their unborn baby; however, a return to smoking after giving birth may occur because they do not appreciate the harmful effects of secondhand smoke exposure on their children (Fang et al.). Interventions that focus on preventing smoking relapse must take these unique postpartum factors into account (Ripley-Moffitt et al.). The prevention of smoking relapse during pregnancy and postpartum is recognized as a critical public health need and important for achieving the goals of Healthy People 2010 (U.S. Department of Health and Human Services, 2000). To date, research and public health efforts have been directed toward helping pregnant women to quit smoking. Although advice from health care providers to quit smoking is necessary, it is not sufficient in that it may miss the large number of women who have already quit smoking and require help to stay that way (Perez-Stable, Marin, & Posner, 1998). Alarmingly high relapse rates underscore the point that maintenance of tobacco abstinence represents the greatest challenge. Greater attention must be directed toward helping women to remain abstinent from smoking throughout their pregnancy and after giving birth (i.e., relapse prevention). The pregnancy and postpartum period represents a true window of opportunity to have a lifelong effect on the health of the woman and her child. Identifying segments of the population most at risk for smoking relapse is a key task in public health prevention efforts. Recent initiatives have focused on ethnic diversity in relation to health and birth outcomes. Hispanics are the largest minority group in the United States and are growing at a rate faster than any other segment of the population (U.S. Bureau of the Census, 2008). In the United States, Hispanics have the highest fertility rate of any ethnic group, accounting for 21% of all births in 2007. It is projected that by 2020, 1 in 4 children will be of Hispanic origin (Federal Interagency Forum on Child and Family Statistics, 2008). Although general population statistics suggest a lower prevalence of smoking among Hispanic women

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than among their non-Hispanic counterparts (Centers for Disease Control and Prevention, 2005), a higher prevalence of smoking is observed among ethnic subgroups of Hispanic women. One study reported that 42% of Puerto Rican women, 25% of Cuban American women, and 23% of Mexican American women are smoking during their prime childbearing years (Roberts-Clarke, Morokoff, Bane, & Ruggiero, 2002). A key consideration when examining smoking rates among Hispanic women is the role of acculturation. Research suggests a strong positive association between acculturation and prevalence of smoking among Hispanic women (Bethel & Schenker, 2005); and highly acculturated Hispanic women are more likely to misclassify their smoking status (i.e., self-report as a nonuser despite biochemical verification of tobacco use; Everhart, Ferketich, Browning, & Wewers, 2009). Recent research demonstrated that level of acculturation does not affect smoking cessation rates among women (Castro et al., 2009). Together, these findings indicate that the effect of acculturation warrants further attention. It is important to note that Hispanic women are more likely to attempt to quit smoking during pregnancy, making them an ideal population for relapse prevention materials (Yu, Park, & Schwalberg, 2002). The majority (95%) of smoking cessation attempts result in relapse (Hughes, Keely, & Naud, 2004). Coping skills training, anticipating high-risk situations, and social support are important elements for successful relapse-prevention interventions (for reviews, see Brandon, Vidrine, & Litvin, 2007; Marlatt & Donovan, 2005). Previous research has demonstrated the efficacy of a series of self-help smoking relapseprevention booklets incorporating these principles, titled Forever Free (Brandon, Collins, Juliano, & Lazev, 2000; Brandon et al., 2004). In one trial, rates of smoking at 2-year follow-up were 21.1% for individuals who received the eight booklets, compared with 36.6% for the comparison group of individuals who received only the first booklet, a relative reduction of 35%. It is important to note that participants in this efficacy study were self-selected, and the general effectiveness of these booklets has not been established. An effectiveness study is ongoing testing the booklets as an adjunct to a state tobacco quitline. The Forever Free booklets have been adapted for pregnant and postpartum women in a series titled Forever Free for Baby and Me (FFBM) and are currently being tested in a randomized, controlled clinical trial. Yet, to date, there is a scarcity of self-help materials available in Spanish for Hispanic smokers. Studies indicate that health education efforts, particularly those with a focus on promoting behavior change, are more successful when transcreated and available to the target population in their native language (Bender, Harbour, Thorp, & Morris, 2001). Transcreation in health education is the process of not only translating the text of written materials into another language, but also infusing culturally relevant context, photos, and themes. In transcreated materials, the text is reconstructed to meet the health literacy and informational needs of the target audience (Quinn, Hauser, Bell-Ellison, Rodriguez, & Frias, 2006; Solomon et al., 2005). The goal of the present study was to translate and adapt existing, theoretically based, smoking relapseprevention materials to create culturally and linguistically appropriate relapse prevention materials for pregnant and postpartum Hispanic women. This article describes the steps involved in the transcreation process used to produce a Spanish-language version of the FFBM smoking relapseprevention booklets. Findings are presented within this framework.

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Methods
Procedures Overview of Transcreation Process We used a multistage qualitative approach to ensure the booklets were linguistically and culturally relevant for the heterogeneous populations of Hispanic women. As a preliminary step in the transcreation process, a certified bilingual translator translated the FFBM booklets from English to Spanish. Because there are differences in Spanish vocabulary and intonation depending on the country of origin (Solomon et al., 2005), the initial translation was subsequently independently reviewed by multiple bilingual professionals representing diverse countries of origin to ensure the Spanish used in the booklets would be understandable to women from different Spanish-speaking backgrounds (e.g., Mexican, Puerto Rican, Cuban, Central and South American). The formative research was conducted in two distinct phases (see Figure 1). This study was approved by the Moffitt Cancer Center Scientific Review Committee and by the University of South Florida Institutional Review Board. Phase I Procedures The overall goal of Phase I was to generate key themes and ideas to be included in the booklets. Specifically, in Phase I, a series of semi-structured in-depth interviews and focus groups were conducted with bilingual participants to explore the information, skill, and social support needs of abstinent and relapsed pregnant and postpartum Hispanic women. A second aspect of Phase I involved providing women with the existing FFBM booklets and asking them to review the booklets and suggest changes for adaptation for monolingual Hispanic women. Two trained bilingualbicultural, native Spanish-speaking interviewers conducted all interviews. Each interview lasted approximately 45 min. Participants received a $25 gift card to a national discount store as compensation for their time. The formative findings from Phase I and a review of the literature were used to inform the development of the adapted Forever Free booklets.

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Figure 1. Overview of qualitative process.

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Phase II Procedures: Learner-Verification Process The suitability of our adaptation was subsequently evaluated through a series of learner-verification interviews in Phase II. Learner-verification interviews, modeled after the research of C. C. Doak, Doak, and Root (1996), were conducted to ensure the cultural suitability of the content and to reduce miscommunication. The learner-verification process is conducted at an individual level to verify the content for comprehension, attractiveness of the booklets, cultural literacy, social acceptability, and persuasion. Women were asked questions such as How appealing is the presentation of this information? and What message is communicated here? Small samples are needed at each stage of this formative research (C. C. Doak, et al.; L. G. Doak, Doak, & Meade, 1996). To ensure that participant suggestions and edits were incorporated accurately, five of the women who participated in Phase I of the study completed learner-verification interviews.

Materials Description of the FFBM Booklets Brandon and colleagues (2000, 2004) have developed the sole smoking relapse prevention self-help program to date, with demonstrated efficacy. The first booklet includes an introduction to basic relapse-prevention principles and techniques. An additional seven booklets cover more extensive information on a topic related to maintaining abstinence: Smoking Urges; Smoking and Weight; What if You Have a Cigarette?; Your Health; Smoking, Stress, and Mood; Lifestyle Balance; and Life Without Cigarettes. The Forever Free booklets have been distributed by the National Cancer Institute (they are available on www.smokefree.gov). The FFBM series has been adapted from the Forever Free booklets and includes 10 booklets designed to address the specific needs of perinatal women. As a result of qualitative formative research, the FFBM series includes two additional booklets: Partner Support and A Time of Change. The Partner Support booklet was written specifically for women to give to their partners and offers information about how to be supportive of a womens efforts to maintain abstinence. A Time of Change was developed to deal with the transition from pregnancy to motherhood, emphasizing the importance of continued abstinence even after giving birth. For more information on the development and content of these booklets, see Quinn et al. (2006). The FFBM booklets are currently being tested in a randomized, controlled clinical trial (Lopez et al., 2008).

Measures Semi-Structured Interview Guide Our research team developed a semi-structured interview guide for the focus groups and interviews. We used standardized, open-ended questions to assess (a) benefits and barriers to quitting smoking, (b) motivations to quit smoking, (c) support provided in the quitting process, (d) sources of health information and trust in these sources, and (e) sources of stress and relaxation. Examples of questions included the following: Has anyone supported your decision and ability to quit smoking? What types of situations are most tempting for you to smoke? and What information should be added to ensure that pregnant=postpartum Hispanic women would pay attention to the information? All interviews were audiotaped.

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Demographic and Smoking History Questionnaire Participants completed a questionnaire assessing demographic information and an assessment of smoking history including number of years smoked and cigarettes smoked per day. Data Analysis We used the verbatim transcripts to develop an initial code list of key themes using open coding. We compiled key points and representative quotes from the participants according to the topics included in the focus group guide. Content analysis was conducted to identify major themes in pregnant and postpartum Hispanic womens beliefs with regard to smoking cessation and relapse. Major themes and supporting quotes were extracted on the basis of frequency and salience. We used a counting analysis (Krueger, 1997) to record the number of instances of each response made by participants. In addition, we used further axial coding to identify discrete categories originally noted during open coding (Strauss & Corbin, 1990). These codes were then compared and combined to develop a big picture summary. The axial coding allowed us to build a conceptual model of the key concepts identified by Hispanic women and to determine whether in each case sufficient data existed to support the interpretation.

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Results
Participant Characteristics Paramount to the transcreation process, participants (n 15) represented diverse countries of origin including Ecuador, Colombia, Mexico, Puerto Rico, Venezuela, Brazil, and Honduras. The average age of the participants was 31.3 years (SD 5.8 years). The majority of participants attempted to quit in the first trimester. Of the participants, 8 had relapsed at the time of the interview: 3 relapsed at some point during their pregnancy, 4 relapsed within 6 months after giving birth, and 1 relapsed more than 1 year after giving birth. Table 1 shows additional participant characteristics. Phase I Results: Qualitative Findings Major themes extracted from the data analyses along with illustrative quotes are subsequently presented. There was a significant degree of overlap in the smoking themes between Hispanic women who relapsed and those who were abstinent. Any meaningful differences between the groups are discussed within each theme. Sources of, and Trust in, Health Information Most women trusted and used the following channels to obtain health information: television (40%), the Internet (33%), magazines (27%), and their health care provider (20%) as their main sources of health information. A few participants noted differences between the manner in which Latin and American television channels presented smoking risk information. I believe that the information from American channels is better than Latin channels because they give better information than the Latin channels.

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V. N. Simmons et al. Table 1. Participant characteristics (N 15) Characteristic Education 12th grade or less Some college and=or degree Marital status Not married Married Employment status Employed Annual income $20,000 >$20,000 Pregnancy status Pregnant Postpartum Timing of quit attempt during last pregnancy Before becoming pregnant First trimester (03 months) Second trimester (36 months) Number of other people smoking in the household 0 1 or more Intentions to smoke after pregnancy To quit smoking forever To quit smoking for the time of the pregnancy Number of years smoking <5 5 Number of cigarettes smoked per day <5 5 n 6 9 7 8 7 8 7 4 11 4 10 1 3 12 7 8 2 13 6 9

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Latin channels do not say that cigarettes are as bad as they really are, they just say smoking is bad for your health. Many women also expressed that they enjoyed reading health related pamphlets while they were in the waiting area of a doctors office, a finding that is relevant to the acceptability of our relapse-prevention booklets. Participants also noted that greater attention is paid to health information that is provided to them by the doctor. Sources of Stress and Relapse Risk Factors The majority of women reported domestic disputes, problems with other children, economic concerns, difficulties surrounding immigration, and isolation as their greatest stressors. Although the primary sources of stress did not vary among abstinent or

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relapsed participants, women who relapsed reported lack of access and understanding of the health system as a relapse risk factor. After having everything (in my country), houses, cars, swimming pools, I lost everything (coming to the US). I believe I am healthier now, but I miss the life I once had. I worked very hard to have what I had. Now I am a better mother, better partner, but I have economic problems. When I am smoking, it is like I am talking to the cigarette. I feel as if someone is there with me.

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Loneliness in this country is bad company. The cigarette is something I distract myself with. Not understanding the health system in this new country makes me feel stressed. I have an urge to smoke when I feel stressed. Many of the women noted how conflict with their partners made quitting and maintaining smoking abstinence challenging. Among abstinent women, other situations that were cited as the most tempting to resume smoking were (a) having a partner who smoked, (b) experiencing negative life events, and (c) attending social events with other smokers. Among the women who resumed smoking, the most frequently cited causes of relapse were (a) stress, (b) partner smoking, and (c) drinking alcohol. Smoking and Weight One of the booklet topics in the FFBM series focuses on smoking and weight, a topic of high relevance for English speaking pregnant and postpartum women (Quinn et al., 2006). The literature suggests that non-Hispanic White women who smoke believe smoking helps to control weight. However, Hispanic women tend to be less likely to smoke as a form of weight control (Johnsen, MacKirnan, Spring, Pingitore, & Sommerfeld, 2002); therefore, to assess the cultural appropriateness of this content, we assessed beliefs about smoking and weight. Findings from our interviews suggest the majority of participants reported worrying about gaining weight; however, they did not associate smoking cessation with weight gain and did not start smoking to lose weight. Coping Strategies An integral component of the booklets is the discussion of cognitive and behavioral coping strategies for dealing with smoking urges. When asked about the methods they used to cope with urges to smoke, many women identified distraction and engagement in relaxing activities as common behavioral coping strategies. Methods of relaxation mentioned frequently were dancing, listening to music, cooking, spending time with family, and going to church or praying. Women who relapsed were more likely to mention drinking alcohol as a form of relaxation. Other women reported that they thought about the consequences of smoking. I remember that I am hurting my baby, and I argue with myself and say, Stop smoking! I need to eat something, or chew gum, to distract myself

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V. N. Simmons et al. I think about the fact that it would be a great tragedy if my smoking resulted in my baby being born with some problem. I tried to quit before my pregnancy because my daughter came to me one day and started crying. She told me that a hole was going to appear in my throat and that I would die and that would make her very sad. This had a great impact on me and I tried to quit but was unsuccessful. It was not until I became pregnant again that I was able to quit.

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Motivation to Quit Smoking and Maintain Abstinence Among both abstinent and relapsed women, the majority of women reported their motivation to quit smoking and desire to remain abstinent centered on their concerns for their children and strong familial pressures. I do not smoke in front of my mother, for respect. My mother never liked cigarettes, nor the idea of someone else smoking and even less for her daughter to smoke. And every time she saw me smoking, she made me feel bad because she looked at me very meanly; it was not a look of caring about me. It was a look of dissatisfaction and rejection. She said to me, You look horrible, you are not beautiful and with cigarettes in your hand, you look horrible. I felt so bad because she told me that in front of other people. I used to tell her, Mom, I am 30 years old, what is wrong with you, and she answered, I do not care, you will always be my daughter. My family looks at me with rejection when I smoke. Social Support We found a significant difference between the abstinent and relapsed groups with respect to the degree of social support provided to the women. The majority of abstinent women noted the support of their partner was a strong factor in remaining smoke free. Many women reported that their spouses had altered their own smoking behaviors in some ways, to help them remain quit. My husband did not quit smoking completely when I was pregnant, but he did not smoke in front of me. He stayed far away from me and after he smoked he washed his hands and asked me if I could still smell the cigarettes to make sure it did not bother me. It has been beneficial for me that my husband quit smoking because he is the person I share the most with, and he was the person whom I had my final cigarette with. For this reason, having his support to quit smoking prevented me from smoking even one cigarette per week. In contrast, most of the women who resumed smoking discussed the challenges of not having any support to quit. My partner tells me that he wants me to quit smoking, but when I say to him that I have not smoked any cigarettes, he tells me that very soon I will resume smoking; he does not recognize my effort to quit.

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Guilt and Stigma The majority of women who relapsed reported feelings of guilt and experiencing a great deal of stigma related to their resumption of smoking. It is important to remember you are not just affecting your health, but also your kids. A mother needs to be a role model. I feel the stigma of smoking is stronger here in the United States compared to [that in] my country. Phase II Results: Learner Verification

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Findings from the series of Phase II learner-verification interviews resulted in significant revisions to the booklets that included modifying the vignettes and changing the graphics throughout the series. These modifications are subsequently described in further detail. Modifications to Vignettes The booklets have been infused with vignettes designed to illustrate the key messages covered in the specific booklet. One goal of this research was to modify these vignettes in order to increase the cultural relevance of the content. This was accomplished by reviewing the literature and by making adaptations on the basis of testimony that the women provided during the interviews. Previous literature illustrates some important cultural differences in motivations to quit, such as a desire to quit smoking because of the effects of smoking on others health. Variables such as experiencing family pressure, damaging ones childrens health, and being a good example to ones children have been demonstrated as strong predictors of wanting to quit (Perez-Stable, Marin, & Posner, 1998; Pletsch & Johnson, 1996). Most women in our study expressed similar familial pressures and concerns for the health of their children as strong motivators to quit smoking and to remain abstinent. Previous research with Hispanic women has also identified the core Hispanic values such as familismo, collectivism, power distance (the respect shown toward authority figures), confianza (trust), and personalismo (personal character) as key considerations to attend to when creating culturally relevant health materials (Saint-Germain, Bassford, & Montano, 1993; Solomon et al., 2005). These key points were considered in the creation of culturally appropriate vignettes throughout the booklets. Learner verification was conducted with each of the new and modified vignettes to verify that the vignettes were acceptable. Data were summarized and revisions were made on the basis of majority responses. Participants responded extremely favorably to the vignettes. The Appendix includes examples of the English and culturally adapted Spanish vignettes to see the manner in which these considerations were incorporated into the vignettes. Graphic Changes Research suggests that many health materials do not include enough Hispanics in photos and illustrations (Perez-Stable, Sabogal, Marin, Marin, & Otero-Sabogal, 1991). Therefore, layout, graphics, and visual elements were adapted to increase the cultural acceptability of the materials. For example, consistent with the familismo component of Hispanic culture, a greater number of photos of extended

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families were included. Further, on the basis of feedback from the learnerverification interviews, images of women with their sister, mother, and grandmother were also included. Photos were also carefully selected to represent the diversity among women from different countries of origin. Qualitative findings from Phase I indicated a strong preference for photos to be included in the booklets to enhance the visual attractiveness of the booklets; thus, efforts were made to increase the number of photos in the booklets. Additional Textual Modifications To enhance the relevance of the stressors discussed throughout the booklets, additions were made to the text to include stressors mentioned most frequently during the focus groups and interviews. An important aspect of the booklets is the discussion of coping strategies to help teach smokers how to cope with urges to smoke. The booklets were adapted to include and highlight methods used frequently by our participants (e.g., praying, dancing, talking with family) to cope with smoking urges.

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Discussion
Nearly half of the U.S. Hispanic population speaks solely Spanish or has limited English proficiency; thus, there is a clear need for health interventions to be available in Spanish. Indeed, one of the significant barriers to reaching Hispanic smokers is language limitations (Wetter et al., 2007). Self-help interventions, written in Spanish, represent an opportunity to increase the reach of smoking cessation and relapseprevention interventions. Furthermore, the need to develop culturally relevant health interventions and measures of health behaviors is receiving greater attention (Kreuter, Lukwago, Bucholtz, Clark, & Sanders-Thompson, 2003) and preliminary evidence suggests such efforts are more efficacious than direct translations alone (McGorry, 2000). Moreover, targeted self-help interventions may be more effective with Hispanic smokers who typically smoke at lower levels than non-Hispanic Whites (Perez-Stable et al., 1991). Hispanic women are also more likely to make a cessation attempt during pregnancy, opening a window of opportunity to provide them with smoking relapse prevention materials in Spanish. Our approach to developing a Spanish version of the FFBM booklets extended beyond mere translation of the text as is more commonly done. Rather, we used multistage qualitative research procedures previously used in the adaptation of health education materials (Quinn et al., 2006; Solomon et al., 2005). The inclusion of women who resumed smoking and those whom continued to abstain was important to identify both risk and protective factors for smoking relapse. Our qualitative findings confirm and extend previous research that suggests ways in which the cultural relevance and acceptability of a health intervention can be enhanced (Perez-Stable et al., 1991; Wetter et al., 2007; Woodruff, Talavera, & Elder, 2002). For example, familismo, an important value in Hispanic cultures, was noticeable in our formative research. Familismo refers to a strong identification and attachment to the nuclear and extended family (Marin, 1991). Several participants discussed the important role of family in increasing their motivation to quit smoking. Results suggests that interventions highlighting the fact that familial cohesiveness can be enhanced by quitting smoking can be a useful way to promote cessation and support continued smoking abstinence among Hispanic smokers. Participants also expressed a strong preference to add more photos to be include

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photos that represented the extended family context. The preference for photographs as supplements to health information among Hispanics has been documented in other contexts such as safety, breastfeeding, and cancer survivorship (Brunette, 2005; Solomon et al.; Stopka, Segura-Perez, Chapman, Damio, & Perez-Escamilla, 2002). Among smokers who quit on their own, relapse rates are as high as 9598% (Hughes et al., 2004). As posited by cognitive-behavioral theoretical models of relapse (Marlatt & Donovon, 2005; Shiffman et al., 1986), and as evidenced by previous research (Shiffman, 1982), individuals who use cognitive and behavioral coping responses are more likely to endure high-risk situations without smoking. The empirically based FFBM booklets thereby focus on teaching the women the following skill sets: (a) how to identify high-risk situations; and (b) how to use coping skills. A booklet in the series titled A Time for Change addresses how to cope with the changes and stressors that occur during the transition between pregnancy and after birth, weight concerns, the reintroduction of smoking cues (e.g., spousal smoking) that were avoided during pregnancy, and increased stress related to caring for a baby (Quinn et al., 2006). Because stress and negative affect represents a high-risk situation related to relapse (Brandon, Tiffany, Obremski, & Baker, 1990), participants were asked about their stressors. Although many of the stressors mentioned in the booklets resonated with participants, several participants discussed stressors that were not represented. Examples of novel stressors included difficulties with the immigration experience, feelings of loneliness=isolation, and lack of access=understanding of the health care system. To enhance the relevance of the content, the booklets were adapted to include these stressors and to place emphasis on these issues in the vignettes. Because the booklets place significant emphasis on the behavioral and mental coping strategies that can be used to combat urges to smoke, the booklets were also adapted to include relaxation techniques and physical activities engaged in most frequently by participants to increase the relevance and likelihood that the strategies would be recalled and used. The limitations of the study must be acknowledged. As with all qualitative studies, results are not intended to be generalizable to other populations. Our sample size was acceptable for qualitative research conducted using maximum variation sampling, with the goal of examining common patterns and variations between two groupsabstinent versus relapsed (Guest, Bunce, & Johnson, 2006); however, our participants were not in the same stage of pregnancy and did not attempt to quit at the same time. Thus, with regards to the distinction between abstainers and relapsers, it is important to note that these groups are not necessarily stable because the women in the abstinent group may relapse at a later point; the groups represent a slice in time. Of note, our findings were consistent with recent qualitative research conducted with White and Black pregnant women, demonstrating a significant degree of overlap in the smoking themes between Hispanic women who relapsed and those who were abstinent (Ripley-Moffitt et al., 2008). It is important to note that we do believe that we reached theoretical saturation with these groups, given that no new themes were emerging and thus our research goals for this study were met. To ensure the Spanish used in the booklets was understandable, we recruited women from diverse countries of origin. Additional research with a larger sample would be needed to determine whether significant differences exist among Hispanic subgroups that would necessitate further adaptation of the booklets. Further research is needed in order to test whether interventions, such as ours, that integrate cultural beliefs and values are indeed more efficacious than standard interventions. Future research should also test the self-help booklets as an adjunct

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to other empirically validated smoking cessation treatments. Few randomized studies have been conducted to test culturally appropriate smoking cessation interventions with Hispanics. More research is also needed to examine culturally specific dissemination routes for smoking interventions. One study conducted by Woodruff and colleagues (2002) demonstrated the short-term efficacy of promotoraslay health advisors who have existing relationships in the communityfor delivering smoking interventions. Future research should explore the efficacy of the promotora approach in enhancing awareness of self-help smoking interventions.

Conclusion
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Results from our study provide important insights into strategies for enhancing the cultural relevance and acceptability of interventions targeted to Hispanic female smokers. Future research will be needed to test the efficacy of these booklets in reducing smoking relapse among pregnant and postpartum Hispanic women.

References
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Appendix: Examples of English and Spanish Vignettes

Key smoking construct targeted in vignette Culturally adapted vignette in Spanish booklets (translated)

Original vignette in English booklets

Key culturally relevant changes Focus on family, loneliness resulting from moving away from family and friends, smoking to belong to new group

Negative affect

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I moved to my new house 5 years ago and I felt very lonely without my family and friends. I started smoking because my new friends also smoked and I wanted to be part of the group. Three months ago, I found out that I was pregnant and I decided to quit smoking. I realized how harmful cigarettes were for me and my baby. I do not want my baby to suffer because of me. I felt scared, however, of losing my friends when I quit smoking. I talked to them, and they supported me by not smoking around me. In fact, one of my friends quit smoking as well. I never realized how much smoking controlled me. I loved having lunch at my grandmothers house,

Benefits of quitting

When, Sadie, our dog of 12 years, passed away, I was so sad. It was very hard to come home to an empty apartment, and I really missed our daily activities taking walks, playing fetch with her. In the past, I had often smoked when I was depressed or feeling lonely, and it was really tough not to give in to the temptation after Sadie died. But, each time I had a strong urge, I would force myself to take a walk, clean the kitchen, play with my daughter, read a book anything to get my mind of smoking. As I got used to life without Sadie, my urges slowly lessened. Now, I am so glad that I was able to remain smoke free. I know that if I had started smoking again, I would have felt worse, not better, in the long run. I never realized how much smoking controlled me. I had always enjoyed hiking but once I became a smoker, I

Focus on family, benefit of increased family cohesion with quitting

(Continued )

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Table 1. Continued

Key smoking construct targeted in vignette Culturally adapted vignette in Spanish booklets (translated)

Original vignette in English booklets

Key culturally relevant changes

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never went anymore because I was short of breath. I loved eating out for lunch with my girlfriends but I stopped going because so many restaurants didnt allow smoking. Now smoking cannot keep me from doing things that I enjoy, Since I quit, I have the freedom to make the choices that I want.

Smoking identity and positive coping strategies

Although she knew it was bad for her, Wendy put off smoking for a long time. Before she became pregnant, Wendy felt that being a smoker was a big part of her identity and her lifestyle. She was afraid that, if she quit smoking for good, she would lose her identity and her lifestyle. She was afraid that if she quit smoking, she would lose her

but she didnt allow anyone smoking. For that reason, I stopped going frequently. Now, smoking cant impede me from the important things. Since I quit smoking, I feel that my family is so much happier, I feel loved and respected by them. Every weekend, we go to my grandmothers house and enjoy all the delicious food she makes. Although she knew it was bad for her, Luisa put off smoking for a long time. Before she became pregnant, Luisa felt that being a smoker was a big part of her identity and her lifestyle. She was afraid that if she quit smoking for good, she would lose her identity and her lifestyle. She was afraid

Focus on culturally relevant activities as examples of positive coping strategies

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identity completely now that she was a mother. Wendy talked about her fears with a good friend who was also a new mother. This friend reminded Wendy that she was a special and interesting woman who was a real friend with a great sense of humor, who enjoyed early 80 s rock music and romantic comedy movies, whose favorite food was black bean chili and so on. Wendy realized that there was more to her than being a wife, or a mother, and that there was more to her than just being a smoker. She saw that she did not need to smoke to be her own person. Focus on relevant stressors

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Stressors

(No English equivalent)

that if she quit smoking, she would lose her identity completely now that she was a mother. Luisa talked about her fears with a good friend who was also a new mother. The friend reminded Luisa that she was a special friend who liked Salsa and Merengue music, soap operas, and whose favorite food was chili with black beans, and so on. Luisa realized that there was more to her than being a wife, or a mother, and that there was more to her than just being a smoker. She saw that she did not need to smoke to be her own person. Natalie recently moved to another city where she doesnt know anyone. Finding a new home, getting legal documents, and finding a new job generated a lot of stress. In addition, she needed to find a new doctor but didnt have any health insurance. Natalie felt bored and very stressed with everything she had to do.