Search tips
Search criteria 


Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
J Health Care Poor Underserved. Author manuscript; available in PMC 2013 October 21.
Published in final edited form as:
PMCID: PMC3804252

Transcreation of Validated Smoking Relapse-Prevention Booklets for use with Hispanic Populations


This report describes the steps taken to develop an evidence-based series of current smoking relapse-prevention booklets for Hispanic smokers.

Keywords: Smoking relapse-prevention, Hispanic smokers, self-help materials

The development and dissemination of evidence-based smoking interventions for diverse audiences is paramount to reduce smoking prevalence rates. Hispanic smokers represent one subgroup of smokers that warrant greater attention with respect to smoking cessation as Hispanics constitute the fastest and largest growing minority group, and represent diverse cultures.1 Although smoking prevalence among Hispanics in the United States (15.8%) is lower than the overall population prevalence (20.6%),2 as acculturation increases, so too does smoking prevalence, eventually approaching the level of non-Hispanic Whites.3 Hispanic smokers face challenges associated with language and cultural barriers to preventative health care in the mainland and do not appear to have equal access to the full range of smoking cessation assistance. For example, Hispanics are less likely to receive tobacco screening and counseling from their physicians4, 5 and are less likely to have ever used nicotine replacement therapy as compared to non-Hispanic white smokers.6, 7 A recent survey of Hispanic smokers who attended a community health fair found that 81.3% had made at least one quit attempt, but none had received smoking cessation counseling, self-help materials, or medication.7

Hispanics smoke fewer cigarettes per day than other ethnic groups8 and report less nicotine dependence; therefore, they may especially benefit from behavioral skill-building.9 Research suggests that culturally tailored interventions can be efficacious,10,11 yet there are few validated substance abuse intervention materials targeted to Hispanics.10,12,13 The United States Public Health Service’s Clinical Practice Guidelines for Treating Tobacco Use and Dependence calls for research on the development and validation of interventions for racial and ethnic minority smokers, with attention to language and cultural factors.14 This recommendation is bolstered by evidence that Hispanic smokers are interested in smoking cessation assistance,7 and that even low-intensity smoking-cessation interventions that are culturally appropriate can be effective with Hispanics.8

Smoking Relapse

Among self-quitting smokers, up to 98% resume smoking within one year, and efficacious treatments yield relapse rates of 60–70%.1416 Although well-formulated theories and comprehensive approaches to prevent relapse exist,1719 recent meta-analyses suggest that the efficacy of relapse-prevention interventions is modest at best.20,21 Moreover, relapse-prevention techniques were initially developed to be incorporated into intensive, face-to-face cessation counseling interventions. However, few smokers are willing to enroll in such intensive programs.22

The purpose of this report is to describe the series of steps that led to the development of smoking-relapse prevention materials for Hispanic smokers and to promote these evidence-based tools.

Self-Help Relapse-Prevention

Over the past 15 years, our group has been developing and testing cost-effective, attractive, and easily disseminable approaches to deliver smoking relapse-prevention interventions. An initial needs assessment revealed two approaches acceptable to former smokers: a telephone hotline and receiving information through the mail.23 A clinical trial comparing these approaches found that the hotline was poorly utilized and ineffective, whereas a series of eight relapse-prevention booklets (now titled Forever Free) was highly effective at reducing relapse among individuals who had three months or less of abstinence at the time of program enrollment.24 By the 12-month follow-up, the booklets had reduced the smoking rate by nearly two-thirds (relapse rates for the relapse-prevention booklets condition and control condition were 12% vs. 35%, respectively) A subsequent clinical trial found reduced relapse through 24 months of follow-up; in addition, mailing the booklets as a single packet was as effective as distributing them over the course of one year.25,26

A more recent project aimed to extend the success of the Forever Free booklets to a population of smokers who are particularly prone to relapse, pregnant, and postpartum women. Women in general face additional barriers to long-term cessation (e.g., less confidence, fear of weight gain, higher levels of negative mood), but the risk of smoking relapse following childbirth is exceptionally high— up to 85% resume smoking postpartum.27,28 The original booklet series covered topics such as smoking urges, managing stress, and social support. However, following a formative evaluation,29 the booklets were targeted for this population by adding a booklet intended for the smoker’s partner (titled Partner Support); adding a new booklet on the transition from pre- to postpartum tobacco abstinence (titled A Time for Change); and modifying the content of the other booklets. Initial findings indicated that the effectiveness of the booklets at extending abstinence, compared with a control condition, was dependent on the level of reported partner support at baseline. For women above the median in perceived partner support, the Forever Free for Baby and Me booklets increased abstinence rates at 8 and 12 months postpartum by approximately 15%.30

After these studies, the National Cancer Institute (NCI) disseminated the Forever Free booklets via the Cancer Information Service and two Websites ( and, and they were adopted by health departments, medical centers, and tobacco quit-lines throughout the country. Seeking to extend the availability of this low-cost intervention to Hispanic smokers, we undertook creating Spanish versions of the Forever Free and the Forever Free for Baby and Me booklets.

Transcreation of Forever Free Interventions

We felt a literal translation of the Forever Free booklets would not suffice. First, patterns of tobacco use among Hispanics differ from those among non-Hispanic Whites.3133 Second, it would be necessary to adapt and validate the smoking relapse-prevention materials for Hispanic smokers culturally and linguistically,34,35 thus we employed methods of transcreation, in which the text is reconstructed to meet the health literacy and informational needs of the group, as well as being translated and culturally adapted.3638 Parallel processes were initiated to create Spanish versions of the Forever Free (Libres para Siempre) and Forever Free for Baby and Me (Libres Para Siempre Por Mi Bebé y Por Mí) smoking relapse-prevention booklets.

The NCI outlines a four-stage systematic and iterative model for the development of a health communication/education program.39 In the Planning and Strategy Development stage, our goal was to learn more about our intended audience (i.e., Hispanic smokers) via literature reviews and to develop a plan for a culturally appropriate version of the booklets.

Developing and Pretesting Concepts, Messages, and Materials

A certified bilingual translator began by completing the direct text translation from English to Spanish. Differences exist in Spanish vocabulary and tone depending on the country of origin,34 necessitating a multiple review process. To improve clarity of the text, four bilingual professionals from diverse countries independently reviewed the booklets to ensure: the Spanish used in the booklets was understandable to individuals from different Spanish-speaking backgrounds; the 6th grade literacy level was maintained; and any difficult-to translate concepts and words were identified.

Formative work continued in two distinct phases. For Phase I, our goal was to conduct a series of qualitative interviews to generate key themes that reflected the information, skill, social support needs, and cultural values of our intended populations. This goal was accomplished by asking bilingual participants to review the existing Forever Free booklets and suggest changes for Spanish-speaking smokers. Areas of discussion included barriers and benefits to quitting, role of support people, and sources of stress and relaxation.

Prior research has proposed methods to enhance the cultural relevance and acceptability of a health intervention.4042 Our findings supported and extended previous studies and are consistent with the conceptualization of cultural sensitivity guided adaptations made at both deep and surface levels as outlined by Resnicow et al.43 For example, familismo, an important value often reported in Hispanic cultures,43,44 was also supported in our formative work. Familismo is defined by a strong identification and attachment to the nuclear and extended family.44 In the current study, familismo (deep level) was reflected in participants’ concerns for how their smoking behavior negatively affects family members and how quitting could benefit their family. As a result, the vignettes (stories designed to illustrate the key messages) in the booklets were modified to reflect these themes, thereby increasing the cultural relevance.

We also enhanced the cultural relevance by identifying specific stressors and methods for coping with stress. Stress and negative affect are high smoking relapse risks;47 thus it was important the stressors mentioned in the booklets resonated with participants. Because Hispanics are disproportionately represented in lower SES groups, financial strain was cited as a barrier to accessing health care and smoking resources. Additional unique issues not represented in the English booklets included difficulties with the immigration experience, feelings of loneliness/isolation, and lack of understanding of the health care system. These specific stressors were incorporated into the vignettes. Important cultural values were also reflected in the manner that participants coped with stressors. Therefore, the list of behavioral and mental coping strategies for combating smoking urges were adapted to fit the audience needs (e.g., praying, spending time with family, cooking, dancing).

During Phase II, the cultural suitability of the adaptations were evaluated through a series of learner verification interviews that entailed verifying the content for comprehension, attractiveness of the booklet, efficacy, acceptability, and persuasion.48, 49 Data collected from this phase resulted in substantial layout, graphic, and visual modifications. Research suggests that health materials lack a sufficient number of Hispanics represented in photos and illustrations,40 a concern echoed by our participants. We included a greater number of photos of extended families (e.g., images of children with their parents and grandparents) to reflect familismo. In addition, photos were also chosen to reflect the diversity among Hispanic individuals from different countries of origin. Specifically, modifying the images in the booklets enabled diverse individual to see that the intervention was targeted for them.43 More details regarding the transcreation process and additional qualitative findings for this phase of the research and illustrative quotations are described in a separate publication.50

Implementing the Program

Consistent with the NCI model described above, our current focus includes continued dissemination, implementation, and evaluation. In addition to placing our materials on NCI websites and regional dissemination of the booklets (throughout Florida), we have distributed the booklets at community health events and health clinics in Puerto Rico. Dissemination efforts are part of an ongoing collaboration between the Moffitt Cancer Center and the Ponce School of Medicine (supported by an NCI Minority Institution/Cancer Center Partnership award).

Assessing Effectiveness and Making Refinements: Adaptation Validation

To close the gap between research and practice, the dissemination of evidence-based information and interventions for use in Hispanic communities must be conducted in a culturally acceptable manner. As an initial step to assess the cultural acceptability of the pregnancy booklets in Puerto Rico, we interviewed health care providers to obtain feedback on the booklets and gain suggestions for culturally appropriate dissemination and implementation.51 Providers praised the overall quality of the booklets, including the interactive activities, vignettes, and the partner booklet. One key issue raised was the importance and value of interpersonal contact and personal relationships for delivering health information. Participants recommended that the booklets be distributed in person, rather than by mail as done with the original English booklets. For example, they suggested distributing the booklets following charlas (health-related themed presentations open to the community), a widely-used medium for providing health information in Puerto Rico.

Current Status and Future Directions

Both the general Libres Para Siempre and the Libres Para Siempre Por Mi Bebé y Por Mí booklets for pregnant women are now available from the corresponding author. In addition, the Libres Para Siempre Por Mi Bebé y Por Mí booklets are available via the NCI Website ( We believe that the process we undertook to transcreate our original Forever Free booklets for Hispanic smokers increases the likelihood that our materials are culturally relevant and efficacious. However, it will be necessary to verify, via a randomized controlled trial, whether these booklets indeed retained the efficacy of the original English versions for reducing smoking relapse. Due to the many commonalities in Hispanic subcultures and the need to develop health interventions that can readily be disseminated in a cost-effective manner, we elected to transcreate our materials to be targeted to, and representative of, Hispanic smokers as a group. Future research is needed to investigate whether there is any value of tailoring the materials by sub-group.52 Further exploration of possible sub-ethnic differences (i.e., by country of origin) is warranted on topics such as perspectives of smoking relapse and preferred dissemination channels.


Preparation of this manuscript and the research reported herein were supported by funding from the National Cancer Institute (R01 CA94256, R01 CA80706, R01 CA137357, U56 CA118809), the American Cancer Society (PBR-94), the March of Dimes Florida Chapter, and the University of South Florida Area Health Education Center.


1. U.S. Census Bureau. Washington, DC: US Dept of Commerce; 2010. [Accessed February 28, 2010]. Facts for features: Hispanic heritage month 2010. [immediate release]. Available at
2. Centers for Disease Control and Prevention (CDC) Cigarette smoking among adults and trends in smoking cessation - United States, 2008. MMWR Morb Mortal Wkly Rep. 2009;58(44):1227–1232. [PubMed]
3. Bethel J, Schenker M. Acculturation and smoking patterns among Hispanics: a review. Am J Prev Med. 2005 Aug;29(2):143–148. [PubMed]
4. Lopez-Quintero C, Crum RM, Neumark YD. Racial/ethnic disparities in report of physician-provided smoking cessation advice: analysis of the 2000 National Health Interview Survey. Am J Public Health. 2006;96:2235–2239. [PubMed]
5. Sonnenfeld N, Schappert SM, Lin SX. Racial and ethnic differences in delivery of tobacco-cessation services. Am J Prev Med. 2009 Jan;36(1):21–28. [PubMed]
6. Levinson AH, Pérez-Stable EJ, Espinoza P, et al. Latinos report less use of pharmaceutical aids when trying to quit smoking. Am J Public Health. 2004 Feb;26(2):105–111. [PubMed]
7. Cupertino AP, Cox LS, Garrett S, et al. Tobacco use and interest in smoking cessation among Latinos attending community health fairs. J Immigr Minor Health. 2010 Oct 9; [PubMed]
8. Fagan P, Moolchan ET, Lawrence D, et al. Identifying health disparities across the tobacco continuum. Addiction. 2007 Oct;102(2 Suppl):58–64. [PubMed]
9. Reitzel LR, Costello TJ, Mazas CA, et al. Low-level smoking among Spanish-Speaking Latino smokers: Relationships with demographics, tobacco dependence, withdrawal, and cessation. Nicotine Tob Res. 2008;11(2):178–184. [PMC free article] [PubMed]
10. Webb MS, Rodríguez-Esquivel D, Baker EA. Smoking cessation interventions among Hispanics in the United States: A systematic review and mini meta-analysis. Am J Health Promot. 2010 Nov-Dec;25(2):109–118. [PubMed]
11. Woodruff SI, Talavera GA, Elder JP. Evaluation of a culturally appropriate smoking cessation intervention for Latinos. Tob Control. 2002;11(4):361–367. [PMC free article] [PubMed]
12. Doolan DM, Froelicher ES. Efficacy of smoking cessation intervention among special populations: review of the literature from 2000 to 2005. Nurs Res. 2006 Jul-Aug;55(4 Suppl):S29–S37. [PubMed]
13. Santisteban D, Vega RR, Suarez-Morales L. Utilizing dissemination findings to help understand and bridge the research and practice gap in the treatment of substance abuse disorders in Hispanic populations. Drug Alcohol Depend. 2006 Sep;84(Suppl 1):S94–S101. [PubMed]
14. Fiore MC, Jaen CR, Baker TB, et al. Clinical Practice Guideline. Rockville, MD: U.S. Public Health Service; 2008. May, Treating Tobacco Use and Dependence: 2008 Update.
15. Brandon TH, Vidrine JI, Litvin EB. Relapse and relapse prevention. Annu Rev Clin Psychol. 2007;3:257–284. [PubMed]
16. Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction. 2004;99:29–38. [PubMed]
17. Marlatt GA. Relapse prevention: theoretical rationale and overview of the model. In: Marlatt GA, Gordon JR, editors. Relapse Prevention. New York: The Guilford Press; 1985.
18. Witkiewitz K, Marlatt GA. Relapse prevention for alcohol and drug problems: that was Zen, this is Tao. Am Psychol. 2004 May-Jun;59(4):224–235. [PubMed]
19. Marlatt GA, Gordon JR, editors. Relapse Prevention: Maintenance strategies in the treatment of addictive behaviors. New York: The Guilford Press; 1985.
20. Hajek P, Stead LF, West R, et al. Relapse prevention interventions for smoking cessation. Cochrane Database Syst Rev. 2009 Jan;21(1):CD003999. [PubMed]
21. Irvin JE, Bowers CA, Dunn ME, et al. Efficacy of relapse prevention: a meta-analytic review. J Consult Clin Psychol. 1999;67:563–570. [PubMed]
22. Cokkinides VE, Ward E, Jemal A, et al. Under-use of smoking-cessation treatments: results from the National Health Interview Survey, 2000. Am J Prev Med. 2005 Jan;28(1):119–122. [PubMed]
23. Brandon TH, DeMichele JT. Expanding the target of relapse-prevention training to include self-quit ex-smokers: is there a need? Psychol Addict Behav. 1995;9(2):114–122.
24. Brandon TH, Collins BN, Juliano LM, et al. Preventing relapse among former smokers: a comparison of minimal interventions via telephone and mail. J Consult Clin Psychol. 2000;68(1):103–113. [PubMed]
25. Brandon TH, Meade CD, Herzog TA, et al. Efficacy and cost-effectiveness of a minimal intervention to prevent smoking relapse: dismantling the effects of content versus contact. J Consult Clin Psychol. 2004;72:797–808. (2004). [PubMed]
26. Chirikos TN, Herzog TA, Meade CD, et al. Cost-effectiveness analysis of a complementary health intervention: the case of smoking relapse prevention. Int J Technol Assess Health Care. 2004 Fall;20(4):475–480. [PubMed]
27. Schnoll AR, Patterson F, Lerman C. Treating Tobacco Dependence in Women. J Womens Health (Larchmt) 2007 Oct;16(8):1211–1218. [PubMed]
28. Fang WL, Goldstein AO, Butzen AY, et al. Smoking cessation in pregnancy: a review of postpartum relapse prevention strategies. J Am Board Fam Pract. 2004 Jul-Aug;17(4):264–275. [PubMed]
29. Quinn G, Ellison BB, Meade C, et al. Adapting smoking relapse-prevention materials for pregnant and postpartum women: formative research. Matern Child Health J. 2006 May;10(3):235–245. [PubMed]
30. Brandon TH, Simmons VN, Khoury EL, et al. Self-help for preventing postpartum smoking relapse: the role of partner support. Presented at: Society for Research on Nicotine and Tobacco Meeting, New Treatments During Pregnancy, DW Wetter (chair); Feb 2010; Baltimore (MD).
31. Bock BC, Niaura RS, Neighbors CJ, et al. Differences between Latino and non-Latino White smokers in cognitive and behavioral characteristics relevant to smoking cessation. Addict Behav. 2005;30:711–724. [PubMed]
32. Daza P, Cofta-Woerpel L, Mazas C, et al. Racial and ethnic differences in predictors of smoking cessation. Subst Use Misuse. 2006;41(3):317–339. [PubMed]
33. Foraker RE, Patten CA, Lopez KN, et al. Beliefs and attitudes regarding smoking among young adult Latinos: a pilot study. Prev Med. 2005 Jul;41(1):126–133. [PubMed]
34. Kreuter MW, Lukwago SN, Bucholtz RD, et al. Achieving cultural appropriateness in health promotion programs: targeted and tailored approaches. Health Educ Behav. 2003;30(2):133–146. [PubMed]
35. McGorry SY. Measurement in a cross-cultural environment: survey translation issues. Qualitative Market Res Int J. 2000;3(2):74–81.
36. Solomon FM, Eberl-Lefko AC, Michaels M, et al. Development of a linguistically and culturally appropriate booklet for Latino cancer survivors: lessons learned. Health Promot Pract. 2005;6(4):405–413. [PubMed]
37. Quinn GP, Hauser K, Bell-Ellison BA, et al. Promoting pre-conceptional use of folic acid to Hispanic women: a social marketing approach. Matern Child Health J. 2006 Sep;10(5):403–412. [PubMed]
38. Bender DE, Harbour C, Thorp J, et al. Tell me what you mean by "si": perceptions of quality of prenatal care among immigrant Latina women. Qual Health Res. 2001 Nov;11(6):780–794. [PubMed]
39. Bethesda, Md: Office of Cancer Communications, National Cancer Institute; 2005. US Department of Health and Human Services: Making health communication programs work. NIH Pub No 05-5145.
40. Perez-Stable EJ, Sabogal F, Marin G, et al. Evaluation of "Guia para Dejar de Fumar," a self-help guide in Spanish to quit smoking. Public Health Rep. 1991;106(5):564–570. [PMC free article] [PubMed]
41. Woodruff SI, Talavera GA, Elder JP. Evaluation of a culturally appropriate smoking cessation intervention for Latinos. Tob Control. 2002;11(4):361–367. [PMC free article] [PubMed]
42. Wetter DW, Mazas C, Daza P, et al. Reaching and treating Spanish-speaking smokers through the National Cancer Institute's Cancer Information Service. A randomized controlled trial. Cancer. 2007 Jan 15;109(2 Suppl):406–413. [PubMed]
43. Resnicow K, Baranowski RK, Ahluwalia JS, et al. Cultural sensitivity in public health: defined and demystified. Ethn Dis. 1999 Winter;9(1):10–21. [PubMed]
44. Marin MG. Applied Social Research Methods Series. vol. 23. London: Sage Publications; 1991. Research with Hispanic populations.
45. Pletsch PK, Johnson MK. The cigarette smoking experience of pregnant Latinas in the United States. Health Care Women Int. 1996;17(6):549–562. [PubMed]
46. Perez-Stable EJ, Marin G, Posner SF. Ethnic comparison of attitudes and beliefs about cigarette smoking. J Gen Intern Med. 1998;13(3):167–174. [PMC free article] [PubMed]
47. Brandon TH, Tiffany ST, Obremski KM, et al. Postcessation cigarette use: the process of relapse. Addict Behav. 1990;15(2):105–114. [PubMed]
48. Doak CC, Doak LG, Root JH. Teaching Patients with Low Literacy Skills. 2nd ed. Philadelphia: JB Lippincott Company; 1996.
49. Doak LG, Doak CC, Meade CD. Strategies to improve cancer education materials. Oncol Nurs Forum. 1996;23(8):1305–1312. [PubMed]
50. Simmons VN, Cruz LM, Brandon TH, et al. Translation and cultural adaptation of smoking relapse-prevention materials for pregnant and post-partum Hispanic women. J Health Commun. (In press). [PubMed]
51. Litvin EB, Rojas AR, Brandon TH, et al. Cultural acceptability of a smoking relapse prevention intervention for pregnant women in Puerto Rico: Providers’ feedback. Hisp Health Care Int. (In press). [PMC free article] [PubMed]
52. Kreuter MW, Wray RJ. Tailored and targeted health communication: Strategies for enhancing information relevance. Am J Health Behav. 2003;27(3 Suppl):S227–S232. [PubMed]