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Differences in quality of life between Hispanic and African American patients with PVD after two years post smoking cessation

Background of the Problem

Cigarette smoking continues to be a serious problem across many population groups and is a significant detriment to health and wellbeing. By the year 2015, it is anticipated that smoking will contribute to approximately 6.5 million deaths throughout the world (Hays et.al, 2010). For smokers, their quality of life is often dramatically reduced as a result of this habit and contributes to many different diseases that could otherwise be prevented (Hays et.al, 2010). Furthermore, smokers from different racial and cultural backgrounds often experience significant disparities in the prevalence of such diseases as cancer and heart disease, particularly in developed countries where many smokers reside (Trinidad et.al, 2011). Therefore, these population groups are at a higher risk of these diseases, as well as other contributing factors, such as poor diet and exercise habits (Baruth et.al, 2011). These creates difficult challenges for many population groups in their efforts to quit smoking and to successfully participate and complete in smoking cessation programs to accomplish their goals and objectives (Trinidad et.al, 2011).

Trinidad et.al (2011) note that smoking cessation efforts amongst non-Hispanic Whites are generally the most successful and contribute to improved outcomes for many persons. However, many African-Americans and Hispanics are hesitant to try or do not complete smoking cessation programs and are often not encouraged to try these programs as compared to Whites (Trinidad et.al, 2011). In addition, some households have established their own smoking bans in some racial and ethnic groups which may contribute to a higher rate of success with smoking cessation programs (Trinidad et.al, 2011). Smoking cessation in the form of nicotine replacement therapy (NRT) has emerged as a viable solution to this problem in an increasing number of cases and represents an opportunity for more populations to utilize this method in the future (Trinidad et.al, 2011). Nonetheless, the problems associated with smoking cessation across different racial and ethnic groups continues to prevail and create disparities in the ability to successfully complete smoking cessation programs within these groups (Trinidad et.al, 2011).

Problem Statement

An area of particular interest is the quality of life of former African American and Hispanic smokers with peripheral vascular disease (PVD) who have successfully completed smoking cessation efforts because these groups provide relevant data and information for future discussion and implementation of smoking cessation efforts across these and other groups. Those persons suffering from PVD, also known as peripheral arterial disease (PAD), have increasingly elected to participated in intensive smoking cessation programs to reduce the risks of smoking and its impact on this serious condition (Hennrikus et.al, 2010). Under these conditions, it is expected that PAD patients will be inclined to attempt to quit smoking in larger numbers and will participate in smoking cessation programs to improve their quality of life (Hennrikus et.al, 2010). However, the long-term impact of smoking cessation on PAD/PVD patients remains to be seen, particularly across different racial and ethnic groups (Hennrikus et.al, 2010).

Purpose of the Study

The primary purpose of the study is to examine the impact of smoking cessation efforts on patients previously diagnosed with PVD/PAD and if this decision is likely to improve quality of life two years after smoking cessation efforts have ended within this group. The consensus indicates that many smokers within this group are willing to commit to smoking cessation programs in an attempt to quit; however, accurate measurements regarding their quality of life years after this effort remains to be seen. It is important to determine how many PVD/PAD patients have successfully quit smoking two years after smoking cessation efforts and for those persons, determine whether or not their quality of life has improved. This is a critical component in measuring the success of smoking cessation efforts for persons who attempt to quit this habit and improve their health as a result over time. These measurements will determine if smoking cessation intervention efforts might be effective for a variety of population groups with different types of diagnoses that contribute to their current quality of life status. In particular, the quality of life for African Americans and Hispanics will be explored in order to determine if these groups experience improved quality of life two years after smoking cessation efforts. This study will explore a smaller group of Hispanics and African Americans who have participated in a smoking cessation program and have completed the program two years prior to the study in order to determine if the smoking cessation experience has had a positive impact on the quality of their lives in their current state of health.

Research Questions/Hypotheses

The most relevant issues to consider will be addressed in the following research questions to determine the impact of smoking cessation on quality of life two years later:

  • What is the prevalence of peripheral vascular disease amongst smokers between the ages of 35-59 versus nonsmokers?
  • Is there a difference between Hispanics and African Americans with respect to the prevalence of peripheral vascular disease?
  • How is smoking cessation a contributing factor to the quality of life to smokers who have completed a smoking cessation program two years prior?
  • What variables should be considered in measuring the quality of life for Hispanic and African American persons with peripheral vascular disease who have completed a smoking cessation program two years prior?

Each of these research questions will be addressed in the following discussion and will demonstrate the most important areas that impact quality of life in this patient population.

Review of the Literature

A vast body of literature has been written to address the challenges associated with smoking amongst many different racial and ethnic groups, including Hispanics and African Americans. It is important to recognize many of these challenges that these groups face in their efforts to address smoking in their lives, whether it is to attempt to quit or reduce their smoking habits as best as possible. The discussion will consider the different impact of smoking behaviours on these population groups and how it impacts their lives in order to determine the prevalence of smoking cessation and its long-term impact on quality of life.

Baruth et.al (2011) consider the role of risk behaviours in the African American population and determine that many people within this group are likely to participate in risk-taking behaviours, such as poor nutrition and diet habits, limited physical activity, and smoking, amongst others. The challenge that many people face is that “Interventions have traditionally focused on changing a single health behaviour. However, there is evidence that people may exhibit more than one risk behaviour at any given time. Although a considerable amount is known about the prevalence of individual risk behaviours, less is known about the patterns or clustering of these behaviours. The extent to which risk behaviours cluster together has implications for program development. If people engage in multiple risk behaviours simultaneously, strategies used to successfully change behaviour are likely to be different than if risk behaviours occur in isolation” (Baruth et.al, 2011, p. 566). Under these circumstances, it is likely that many African Americans exhibit clustered behaviours and are less willing or find it more difficult to curb several risk behaviours rather than a single behaviour (Baruth et.al, 2011). Therefore, when considering prevention tactics and other programs for these individuals, it is often necessary to develop strategies that encompass multiple risk-taking behaviours if at all possible (Baruth et.al, 2011). The study indicates that there are a number of risk behavior clusters, including those associated with diet and physical activity; however, smoking appears to be a separate matter altogether and is not necessarily considered in the same manner as diet and exercise, although there is a tendency for smokers to also have poor diet and physical activity habits (Baruth et.al, 2011). This study indicates that additional research is required to ensure that intervention programs for these population groups address several risk-taking behaviours at the same time rather than single behaviours, which may be a counterproductive measure for these groups (Baruth et.al, 2011).

A study by Wolma et.al (2009) addresses the relevance of large and small-vessel diseases in Blacks and Whites and considers the impact of ethnicity and ischemic strokes. Ethnicity is a key factor in large and small-vessel diseases; therefore, it is important to address these challenges and how they impact Blacks and Whites (Wolma et.al, 2009). The study determined that Whites have a greater tendency to develop large-vessel disease versus non-Whites and that this condition is further exacerbated by ischemic stroke (Wolma et.al, 2009). On the other hand, Blacks and other non-White patients typically present with small-vessel disease; nonetheless, Blacks have a greater tendency for strokes than Whites (Wolma et.al, 2009). In this case, ethnicity is a critical factor in the prevalence of ischemic stroke and should also be considered in the presence of smokers versus non-smokers (Wolma et.al, 2009). The study indicates that additional research is required with these population groups in order to determine the impact of smoking and ethnicity on the prevalence of small and large-vessel disease and subsequent ischemic stroke (Wolma et.al, 2009).

In the Hispanic/Latino population, it is important to recognize the changing demographics of this group and how this contributes to their ability to participate and communicate in a variety of programs in different settings (O’Hegarty et.al, 2010). It is important to address the challenges of communicating with this population regarding smoking habits to obtain an expanded assessment of the degree to which they might be receptive to smoking cessation programs (O’Hegarty et.al, 2010). As a result, it is necessary to consider these challenges and their overall impact on this population group by implementing a detailed survey instrument to obtain knowledge regarding smoking habits and preferences (O’Hegarty et.al, 2010). In those populations that are difficult to reach due to language barriers or geographic locations, survey instruments may effectively fill those gaps to achieve the desired outcomes, particularly with minority populations (O’Hegarty et.al, 2010).

An article by Cupertino et.al (2011) demonstrates the impact of smoking cessation in the Latino population, with a focus on visibility and promotion during health fairs. The study considered the influence of smoking cessation on a largely male group of participants, primarily classified as light smokers, and determined that the large majority of these individuals were not aware of the opportunity to enter a smoking cessation program with free individualized counseling (Cupertino et.al, 2011). Therefore, underserved populations are likely to benefit from programs that are highlighted at health fairs for which participation is encouraged (Cupertino et.al, 2011). Therefore, health fairs provide a positive resource for many Latino individuals with language barriers and may advance their participation in smoking cessation efforts (Cupertino et.al, 2011).

It is known that smoking rates in the adult Hispanic population are around 20 percent; however, some of the smaller subgroups that exist possess higher rates, such as Mexican Americans (O’Hegarty et.al, 2013). Within Hispanic communities, there is a greater likelihood that older smokers will commit to and be successful with cessation programs of both genders, and both groups largely forbid smoking in the home environment (O’Hegarty et.al, 2013). Based upon existing research, it is known that “Using culturally specific surveys can help empower communities to direct program planning and evaluation, determine health priorities, and develop specific intervention strategies and policies targeting local communities” (O’Hegarty et.al, 2013, p. 254). These efforts also demonstrate the potential positive impact of smoking cessation on these groups once knowledge is well-defined and supported by groups that serve these communities (O’Hegarty et.al, 2013).

For African American women who depend on public housing, smoking cessation programs have low to moderate results over the long term and are not impacted by such factors as spirituality (Andrews et.al, 2007). However, the most positive impact of this type of program is associated with a nurse-led intervention to perform outreach and to make a greater effort to connect with members of this population group in their own surroundings (Andrews et.al, 2007). Furthermore, it is evident that a higher level of social support for a smoking cessation intervention will better motivate these individuals and their ability to be successful in quitting their smoking habits for good (Andrews et.al, 2007). Another study conducted with African Americans demonstrated that the concept of planned behavior is likely to have a greater impact on their ability to effectively use smoking cessation efforts, and most effectively when they are associated with physician involvement and intervention as referents (Lynam et.al, 2012).

Smoking cessation in some population groups is more successful than in others; therefore, it is important to recognize these differences and to examine different opportunities for growth and development in this area of study. Trinidad et.al (2010) considered these trends and the differences between population groups in an effort to determine if the use of mentholated cigarettes has any real impact on smoking cessation efforts for different racial and ethnic groups. The study explored a number of different criteria in order to explore the benefits of smoking cessation and its popularity amongst these groups, and in particular, those persons who smoke mentholated cigarettes (Trinidad et.al, 2010). Statistics demonstrate that “Approximately 70% of African American adult smokers choose mentholated cigarettes, compared to fewer than 30% of other racial/ethnic groups… This has led to speculation that smoking mentholated cigarettes enhances the harmful effects of cigarette smoking and makes it more difficult to quit smoking” (Trinidad et.al, 2010, p. 84). Under these circumstances, it is evident that there are significant factors associated with smokers who regularly use mentholated cigarettes versus those who use regular cigarettes; therefore, these perspectives must be considered in greater detail in order to emphasize the importance of the increased dangers associated with mentholated cigarettes and a higher level of addiction that may be more difficult to overcome than that of regular cigarettes (Trinidad et.al, 2010). It is important to recognize these differences because they are also likely to contribute to the development of smoking cessation programs that are different and more effective for menthol cigarette smokers versus traditional cigarette smokers, thereby leading to improved benefits for some population groups, such as African Americans (Trinidad et.al, 2010).

Smoking cessation efforts amongst groups with lower incomes was examined using portable technology (personal digital assistants) to facilitate this process, and it was determined that the most complicated factor was the technology itself and not the smoking cessation program and the ability to follow it for the desired period of time (Buchanan and Khazanchi, 2010). It is believed that “Clients with socioeconomic vulnerability may be pressured by friends to smoke and are targets of tobacco company advertisements and promotions, making it difficult to sustain smoking cessation…spouses, friends, and coworkers who smoke can sabotage efforts to quit, suggesting that relationships with current smokers be avoided for the short term until skills learning is established” (Buchanan and Khazanchi, 2010, pp. 283-284). This study demonstrated that additional evaluation is required to determine if portable technology will serve as an effective tool in promoting smoking cessation efforts, particularly in vulnerable population groups (Buchanan and Khazanchi, 2010). It is expected that additional studies and frameworks will also provide greater benefits to smokers who require some degree of intervention and/or motivation in the home environment, where it is likely that motivation is lacking in many cases (Buchanan and Khazanchi, 2010).

Studies have shown that there are significant differences between Blacks and Whites with respect to smoking behaviors, with Blacks smoking fewer cigarettes and in smaller numbers (Carter et.al, 2010). For smokers, the nicotine craving is perhaps the most difficult component of breaking this habit because over time, a dependency on nicotine is evident and reduces the ability of many smokers to succeed with cessation efforts (Carter et.al, 2010). Therefore, nicotine cravings typically drive the tendency to smoke during different periods throughout the day (Carter et.al, 2010). These findings suggest that it is important to consider the differences in nicotine cravings between Black and White smokers in order to determine if other factors play a role in these cravings within the two population groups (Carter et.al, 2010). The study also supports the belief that Blacks are likely to have more intense nicotine cravings due to the stressors of daily living that many Whites may not experience (Carter et.al, 2010). As a result, it is necessary to consider the different features that distinguish Blacks from Whites with respect to their smoking cravings and to further emphasize Blacks and their smoking-related behaviors to determine how to provide the most effective smoking cessation treatments that meet their needs (Carter et.al, 2010). The specificity of smoking cessation programs provides important benefits to this population group and addresses some of the most important challenges related to smoking cessation and the ability to quit smoking on a more permanent basis (Carter et.al, 2010).

Patients who face peripheral artery disease must also consider their risk factors, including the tendency for this condition in the African American population (Ix et.al, 2008). In general, African Americans have greater risk markers in several areas, such as hypertension and diabetes; at similarly, they possess a tendency for risk markers that contribute to cardiovascular disease (Ix et.al, 2008). It is believed that a greater risk of peripheral artery disease is also associated with cardiovascular disease, based upon several serum risk markers and concentrations that have a higher prevalence in African Americans (Ix et.al, 2008). Based upon a research study, there was a three times greater likelihood of peripheral artery disease in African Americans than Whites, particularly when there is a previous diagnosis of peripheral artery disease (Ix et.al, 2008). Therefore, it is important to recognize these limitations and to consider other factors which demonstrate that there is a greater tendency for African Americans to be diagnosed with peripheral artery disease than Whites, including the possibility of cardiovascular disease as a key risk factor in many but not all cases (Ix et.al, 2008). Additional studies are necessary to address this correlation in greater detail to determine this relationship in clinical settings (Ix et.al, 2008).

For patients with peripheral arterial occlusive disease (PAOD) and coronary artery disease (CAD), it is important to recognize the different impacts of these conditions on the development of successful programmatic efforts to manage symptoms in an outpatient setting (Jeger et.al, 2008). This is an important tool because it contributes to the overall understanding of the relationship between these conditions, which include the common risk factor of cigarette smoking (Jeger et.al, 2008). The ability of patients with PAOD to obtain outpatient cardiac rehabilitation (OCR) therapy may be limited by the belief that these treatments will not provide effective benefits (Jeger et.al, 2008). Therefore, it is necessary to consider these objectives and to determine how to best approach OCR and if it is appropriate for PAOD patients (Jeger et.al, 2008). The authors indicate that “It can be hypothesized that effects of rehabilitation including supervised physical activity, risk factor modification, education, and counseling might be similar in the atherosclerotic disease of different vascular beds. However, patients with CAD who suffer from PAOD might not be referred to rehabilitation programs due to decreased exercise capacity, limiting symptoms, and less anticipated benefit” (Jeger et.al, 2008, p. 620). This hypothesis indicates that the benefits of OCR are not always obtained by patients with PAOD because of the belief that they have limited impact; therefore, this area of study must be examined more closely in future studies (Jeger et.al, 2008).

For patients who suffer from peripheral arterial disease, it is important to consider the different symptoms and other risk factors that contribute to severely negative outcomes, such as the loss of limbs (Collins et.al, 2007). For this patient population, it is believed that these negative outcomes may be avoided or minimized in patients who improve their glucose monitoring and demonstrate their willingness to conduct efforts to also reduce renal dysfunction and the impact of demographics (Collins et.al, 2007). These conditions are important because they provide further evidence of the devastating potential of PAD in patients when a level of control is not achieved and how this impacts their short and long term wellbeing (Collins et.al, 2007). Patients of African American origin are likely to experience more significant symptoms and adverse events as a result of PAD; therefore, this population group must be explored in depth in future studies to determine how to minimize these risks and preserve the quality of life for longer periods of time (Collins et.al, 2007).

From a psychological perspective, it is important to consider the different aspects of smoking cessation efforts that are conducted over the short term, particularly for patients with peripheral artery disease (Dickinson et.al, 2009). Prior to surgery, some patients continue to smoke and increase their risk of chronic illness and other conditions and must consider these risks in promoting health and wellbeing (Dickinson et.al, 2009). However, it should be noted that even short term smoking cessation efforts may have a positive impact on patients and provide a level of support for their ability to quit this habit on a long term basis (Dickinson et.al, 2009). In addition, it is known that “telling smokers their ‘‘lung age’’ as measured by spirometry significantly improved the likelihood of smoking cessation… It has also been demonstrated that showing smokers pictures of their own atherosclerotic carotid arteries increases both motivation for smoking cessation and the actual cessation rate” (Dickinson et.al, 2009, p. 160). In this context, the ability to “shock” patients by providing them with disturbing information regarding their smoking habits may have a positive impact on their ability to quit this habit on a permanent basis, particularly when they recognize the dangers of this practice and how it impacts overall lung function (Dickinson et.al, 2009).

The research articles that have been addressed provide further evidence that the impact of smoking cessation efforts for many population groups remain largely unknown and are not considered to be universally successful. Therefore, it is important to address these findings and the opportunities that are available to further enhance smoking cessation as a means of promoting improved health and wellbeing for many people, particularly those in minority groups where access to healthcare and preventative measures may be limited. The study of patients with peripheral artery disease is of particular interest and the influence of smoking on this population is highly relevant. In addition, it is expected that this population will also achieve some degree of benefit from the provision of smoking cessation programs to enable individuals to quit smoking more successfully and on a permanent basis. Therefore, the proposed study involving patients of Hispanic or African American origin and the impact of smoking cessation two years later on their quality of life is both warranted and significant in potentially shaping the wellbeing of these population groups.

Methodology

In order to successfully carry out the proposed research study, it is important to address the different areas that are instrumental in supporting the development of a study that successfully captures the proposed research questions. For this study, it is important to consider how different elements in other research studies have performed in the past and to establish a greater understanding of which elements are appropriate for the proposed study. Under these conditions, it is likely that the chosen elements will consider different ideas and approaches to support the research questions and the necessity to address specific elements appropriately. For the purposes of this research topic, it is important to include both African American and Hispanic participants who have completed a smoking cessation program in the past and who have been diagnosed with peripheral arterial disease. It is important to utilize the same type of smoking cessation program for the study so that there is some degree of consistency with the study results. This will capture the key elements that are necessary to achieve the desired outcomes in an effective manner.

The proposed research study should also consider a relatively small population group because there is a lengthy time element involved. The number of participants must be significant enough to make a difference but should not be so large that data collection is not a feasible task. Therefore, a balance must be drawn between these two objectives to achieve realistic results that are applicable to the study population. In addition, it is important to consider other factors that are relevant to the proposed population, such as socioeconomic conditions, communication barriers, and general cultural differences that could impact the study results. For each of these criteria, it is evident that there must be a framework in place that will maintain the research focus and will support accurate results.

Design

The proposed research design will utilize a correlational longitudinal approach, which will address the impact of the selected smoking cessation program for Hispanics and African Americans with peripheral arterial disease two years after the program has been completed. The longitudinal research design is appropriate for this study because it reflects the capacity to evaluate study participants at the desired intervals over lengthier periods of time and provides further evidence that will contribute to the study results and any subsequent recommendations that are required. These efforts will also provide additional evidence in supporting the original research claims, such as the ability of smoking cessation programs to improve the quality of life for successful achievers after a two-year period of time. The longitudinal approach has the benefits of observing a study cohort well into the future to identify specific data elements. However, it may also be time intensive and very expensive to manage; therefore, it is likely that this type of study will be best suited for a smaller number of study participants to minimize costs and the time that will be spent conducting the study and performing the data analysis.

Sample

The proposed study sample must be achieved using a specific method to obtain the most appropriate sample for the research protocol under consideration. The proposed sampling method that would best meet the needs of the research study is the purposive sampling approach, which is based upon the identification of study participants from one or more very specific groups who meet the established criteria. This is an effective tool in demonstrating the necessity to focus on a smaller segment of one or more population groups to achieve the study objectives. For the purposes of this study, it is evident that the study group will include only those individuals from Hispanic and African American groups who have been diagnosed with peripheral arterial disease and who have completed a successful smoking cessation program two years prior. Therefore, it is important to target a study population that is from the same group of individuals who participated in the same smoking cessation program at the same time. This will ensure that the study population is specific enough and is also small enough to work with effectively in a longitudinal study of this nature.

Setting

The most ideal setting for the proposed study is a metropolitan area and the surrounding suburbs where there are high concentrations of Hispanics and African Americans. This will ensure that the study population is appropriate and that there are sufficient numbers of prospective participants to choose from in order to achieve the desired results. The study population should be derived from a database of patients within a specific geographic region who have been diagnosed with peripheral arterial disease and who have completed a smoking cessation program two years prior. These two criteria are critical in addressing the proposed research questions and in drawing conclusions regarding this study population and the impact of smoking cessation on quality of life over a longer period of time.

Data Collection

For a longitudinal study, the most appropriate method of data collection is the face-to-face interview and follow-up survey, both of which are likely to provide the type of data that is necessary to achieve the desired outcomes. In addition, it is important to address these findings and to consider the research questions and the impact of the selected data and results on addressing these questions in greater detail. By conducting individual face-to-face interviews, the interviewer will be able to ask the appropriate questions and to obtain a variety of responses from which additional analyses and measurements will be derived. In addition, a single follow up survey is also proposed as a means of evaluating the selected study participants and their experiences during the interview process to reduce any type of bias or other factors that might contribute to future studies.  It is imperative to properly collect, assess, and keep all data private and confidential by using random numbers or other identifiers in lieu of names and other personal information. This will achieve the desired level of protection of human subject data, in conjunction with the required approvals from the institutional review board. This is an important contributor in protecting the integrity of the data as necessary to promote study validity and applicability to future studies.

Measures

It is important to address how to best measure the data that is collected in the study to protect its integrity, validity, and reliability. This is best accomplished by using an approach that minimizes the variety of responses that will be obtained during the face-to-face interviews and the follow up surveys. This is an important task in order to demonstrate the impact of the study data and its impact on achieving the desired outcomes. Patients who are selected for study participation should also complete all elements of the study in full so that there is the greatest potential for accuracy in the data collection phase of the study. It is imperative to consider the different variables that must be incorporated into the two phases of data collection, including but not limited to quality of life, the degree of success of the smoking cessation program, the degree of severity of peripheral arterial disease, and other related factors. Each of these concepts will demonstrate the effectiveness of the data collection portion of the study and its impact on addressing the research questions.

Analysis

The data analysis portion of the study must demonstrate the impact of the face-to-face interviews and follow up survey in supporting the research questions. This will be obtained by using statistical analyses that are derived by using SPSS software. In addition, the most appropriate analysis method is the random coefficient model, whereby regression analyses are conducted to analyze the data that has been derived from the interviews and surveys It is important to utilize a method of this nature because it reflects a capacity to examine the data from a variety of perspectives and to address the desired research questions more thoughtfully. This is an important tool that will demonstrate the impact of the data collection techniques and if they have been successful in addressing the research questions. It is believed that the study will provide meaningful results regarding the study population. However, the study will be self-limiting due to the time and expense required to perform a longitudinal study; therefore, only a small group of participants will be selected for participation. Therefore, it is likely that additional studies will be required in the future to further address the issues under consideration and the impact of smoking cessation on the Hispanic and African American populations who have been diagnosed with peripheral arterial disease. Since quality of life is a challenging measurement to begin with, it is expected that there will be additional studies required in the future to also measure this variable in greater detail and to identify any other factors which may contribute to successful study outcomes.

References

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Baruth, M., Addy, C.L., Wilcox, S., and Dowda, M. (2012). Clustering of risk behaviours among                      African American adults. Health Education Journal, 71(5), 565-575.

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Ix, J.H., Allison, M.A., Denenberg, J.O., Cushman, M., and Criqui, M.H. (2008). Novel             cardiovascular risk factors do not completely explain the higher prevalence of                  peripheral artery disease among African Americans. Journal of the American                       College of Cardiology, 51(24), 2347-2354.

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O’Hegarty, M., Pederson, L.L., Thorne, S.L., Caraballo, R.S., Evans, B., Athey, L., and             McMichael, J. (2010). Customizing survey instruments and data collection to reach                    Hispanic/Latino adults in border communities in Texas. American Journal of                        Public Health, 100(S1), S159-S164.

O’Hegarty, M., Pederson, L.L., Asman, K., Thorne, S.L., and Caraballo, R.S. (2013). Tobacco              use, cessation, and home smoking rules in a Hispanic community. American Journal             of Health Behaviour, 37(2), 248-256.

Trinidad, D.R., Perez-Stable, E.J., White, M.M., Emery, S.L., and Messer, K. (2011). A                         nationwide analysis of US racial/ethnic disparities in smoking behaviours, smoking                    cessation, and cessation-related factors. American Journal of Public Health, 101(4),                   699-706.

Trinidad, D.R., Perez-Stable, E.J., Messer, K., White, M.M., and Pierce, J.P. (2010). Menthol                cigarettes and smoking cessation among racial/ethnic groups in the United States.                                   Addiction, 105(Suppl 1), 84-94.

Wolma, J., Nederkoom, P.J., Goossens, A., Vergouwen, D.I., van Schaik, I.N., and Vermeulen,             M. (2009). Ethnicity a risk factor? The relation between ethnicity and large- and small-                    vessel disease in White people, Black people, and Asians within a hospital-based                        population. European Journal of Neurology, 16, 522-527.